Provider Demographics
NPI:1497912984
Name:PATRICKUS, JOHN E (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:PATRICKUS
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 1:2343 E MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-3764
Mailing Address - Country:US
Mailing Address - Phone:920-468-8144
Mailing Address - Fax:
Practice Address - Street 1:2343 E MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-3764
Practice Address - Country:US
Practice Address - Phone:920-468-8144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001185122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000176990Medicare PIN
WIT62960Medicare UPIN