Provider Demographics
NPI:1760850614
Name:BOETTCHER, MICHELLE (RDH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BOETTCHER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2552 S BRISBANE AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-1502
Mailing Address - Country:US
Mailing Address - Phone:414-477-2904
Mailing Address - Fax:
Practice Address - Street 1:2552 S BRISBANE AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-1502
Practice Address - Country:US
Practice Address - Phone:414-477-2904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002491-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist