Provider Demographics
NPI:1639338445
Name:LEDVINA, GEORGE RICHARD III (DDS)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:RICHARD
Last Name:LEDVINA
Suffix:III
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 1:9401 W BELOIT RD
Mailing Address - Street 2:#310
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-4357
Mailing Address - Country:US
Mailing Address - Phone:414-545-0147
Mailing Address - Fax:
Practice Address - Street 1:9401 W BELOIT RD
Practice Address - Street 2:#310
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4357
Practice Address - Country:US
Practice Address - Phone:414-545-0147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00030621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice