Provider Demographics
NPI:1164109336
Name:ELMADAWY, TARIQ
Entity Type:Individual
Prefix:DR
First Name:TARIQ
Middle Name:
Last Name:ELMADAWY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 MARINA CIR UNIT 502
Mailing Address - Street 2:
Mailing Address - City:ASHWAUBENON
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4877
Mailing Address - Country:US
Mailing Address - Phone:734-502-8196
Mailing Address - Fax:
Practice Address - Street 1:1551 PARK PL STE 300
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1969
Practice Address - Country:US
Practice Address - Phone:920-332-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001237-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty