Provider Demographics
NPI:1639280811
Name:MASEL, JOHN PHILLIP (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILLIP
Last Name:MASEL
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 1:2130 W BOLIVAR AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2214
Mailing Address - Country:US
Mailing Address - Phone:414-282-9783
Mailing Address - Fax:
Practice Address - Street 1:1401 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4623
Practice Address - Country:US
Practice Address - Phone:414-671-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5001685OtherDENTAL LICENSE