Provider Demographics
NPI:1508492885
Name:CARPENTER, MAX
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:CARPENTER
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 1:1210 N 62ND ST APT 321
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3063
Mailing Address - Country:US
Mailing Address - Phone:616-558-3697
Mailing Address - Fax:
Practice Address - Street 1:3522 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:414-935-8000
Practice Address - Fax:414-935-8011
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002306-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist