Provider Demographics
NPI:1629050026
Name:GERNETZKE, JOHN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:GERNETZKE
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 1:109 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1319
Mailing Address - Country:US
Mailing Address - Phone:608-882-4441
Mailing Address - Fax:608-882-4967
Practice Address - Street 1:109 S MADISON ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1319
Practice Address - Country:US
Practice Address - Phone:608-882-4441
Practice Address - Fax:608-882-4967
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4078122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33688500Medicaid
WI33688500Medicaid