Provider Demographics
NPI:1760733075
Name:LIST, GLORIA T (DDS)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:T
Last Name:LIST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13105 WATERTOWN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2213
Mailing Address - Country:US
Mailing Address - Phone:262-782-1460
Mailing Address - Fax:262-782-0093
Practice Address - Street 1:13105 WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2213
Practice Address - Country:US
Practice Address - Phone:262-787-1460
Practice Address - Fax:262-782-0093
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000062-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice