Provider Demographics
NPI:1609444363
Name:GELICHE, MADISON ROSE (DMD)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ROSE
Last Name:GELICHE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1622
Mailing Address - Country:US
Mailing Address - Phone:262-654-0267
Mailing Address - Fax:
Practice Address - Street 1:3415 30TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1622
Practice Address - Country:US
Practice Address - Phone:262-654-0267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002562-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist