Provider Demographics
NPI:1619286408
Name:DENTINO, MONICA L (CCC-A)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:L
Last Name:DENTINO
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:L
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-A
Mailing Address - Street 1:3230 OLD LANTERN DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-3016
Mailing Address - Country:US
Mailing Address - Phone:262-783-7731
Mailing Address - Fax:
Practice Address - Street 1:3230 OLD LANTERN DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-3016
Practice Address - Country:US
Practice Address - Phone:262-783-7731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI198-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00959860OtherRAILROAD
WI1619286408Medicaid
P00959860OtherRAILROAD