Provider Demographics
NPI:1326191099
Name:RADKE, THOMAS J (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:RADKE
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 1:6919 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-2916
Mailing Address - Country:US
Mailing Address - Phone:414-545-8226
Mailing Address - Fax:414-543-4805
Practice Address - Street 1:6919 W FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-2916
Practice Address - Country:US
Practice Address - Phone:414-545-8226
Practice Address - Fax:414-543-4805
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3977122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist