Provider Demographics
NPI:1245221977
Name:CIEPLUCH, RANDY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:R
Last Name:CIEPLUCH
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 1:3500 W LISBON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-1953
Mailing Address - Country:US
Mailing Address - Phone:414-342-0378
Mailing Address - Fax:414-342-1008
Practice Address - Street 1:3500 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1953
Practice Address - Country:US
Practice Address - Phone:414-342-0378
Practice Address - Fax:414-342-1008
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2260-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33387500Medicaid