Provider Demographics
NPI:1124374012
Name:RADKE, ANN M
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:RADKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13710 MAYFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-7618
Mailing Address - Country:US
Mailing Address - Phone:708-207-9012
Mailing Address - Fax:
Practice Address - Street 1:13710 MAYFLOWER LN
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-7618
Practice Address - Country:US
Practice Address - Phone:708-207-9012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-28
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020014035124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist