Provider Demographics
NPI:1417050097
Name:MACHULAK, GREGORY (DDS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MACHULAK
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 1:3705 NORTH 92ND STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2501
Mailing Address - Country:US
Mailing Address - Phone:414-464-5470
Mailing Address - Fax:
Practice Address - Street 1:3705 NORTH 92ND STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-2501
Practice Address - Country:US
Practice Address - Phone:414-464-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001887122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist