Provider Demographics
NPI:1528000304
Name:PELKOWSKI, THOMAS B (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:B
Last Name:PELKOWSKI
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 1:3076 RED FOX CIR
Mailing Address - Street 2:
Mailing Address - City:COLGATE
Mailing Address - State:WI
Mailing Address - Zip Code:53017-9544
Mailing Address - Country:US
Mailing Address - Phone:262-397-7708
Mailing Address - Fax:
Practice Address - Street 1:3076 RED FOX CIR
Practice Address - Street 2:
Practice Address - City:COLGATE
Practice Address - State:WI
Practice Address - Zip Code:53017-9544
Practice Address - Country:US
Practice Address - Phone:262-397-7708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001186-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33705300Medicaid