Provider Demographics
NPI:1114121563
Name:DKEIDEK, ISSA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ISSA
Middle Name:
Last Name:DKEIDEK
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 1:1014 N ASTOR ST
Mailing Address - Street 2:APT 23
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3317
Mailing Address - Country:US
Mailing Address - Phone:716-713-2613
Mailing Address - Fax:
Practice Address - Street 1:11711 W BURLEIGH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-3108
Practice Address - Country:US
Practice Address - Phone:800-315-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6107 - 15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist