Provider Demographics
NPI:1033204557
Name:RADKE, DENNIS L (DDS)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:L
Last Name:RADKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 EAST DIVISION
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345
Mailing Address - Country:US
Mailing Address - Phone:616-887-8228
Mailing Address - Fax:616-887-1850
Practice Address - Street 1:72 EAST DIVISION
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345
Practice Address - Country:US
Practice Address - Phone:616-887-8228
Practice Address - Fax:616-887-1850
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI116701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4044890Medicaid