Provider Demographics
NPI:1821194184
Name:MACKMAN, JAY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:L
Last Name:MACKMAN
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 1:2626 N 76TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213
Mailing Address - Country:US
Mailing Address - Phone:414-476-9400
Mailing Address - Fax:
Practice Address - Street 1:2626 N 76TH ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213
Practice Address - Country:US
Practice Address - Phone:414-476-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2793-0151223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
T62660Medicare UPIN