Provider Demographics
NPI:1609240472
Name:DORSEY, TIA (RDH)
Entity Type:Individual
Prefix:MS
First Name:TIA
Middle Name:
Last Name:DORSEY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 W NORTH AVE
Mailing Address - Street 2:APT# 202
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-1269
Mailing Address - Country:US
Mailing Address - Phone:414-517-5653
Mailing Address - Fax:
Practice Address - Street 1:1730 S 13TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3201
Practice Address - Country:US
Practice Address - Phone:414-383-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10912-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist