Provider Demographics
NPI:1043611155
Name:GOLOVIN, ALICIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:
Last Name:GOLOVIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE # MS 958
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:5433 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-1382
Practice Address - Country:US
Practice Address - Phone:414-445-6500
Practice Address - Fax:414-445-6618
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10011391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043611155Medicaid