Provider Demographics
NPI:1821213653
Name:ANTISDEL, CAROL JEAN (D,D,S,)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:JEAN
Last Name:ANTISDEL
Suffix:
Gender:F
Credentials:D,D,S,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 E GREEN BAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080-2013
Mailing Address - Country:US
Mailing Address - Phone:262-284-7111
Mailing Address - Fax:262-284-1172
Practice Address - Street 1:661 E GREEN BAY AVE
Practice Address - Street 2:
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080-2013
Practice Address - Country:US
Practice Address - Phone:262-284-7111
Practice Address - Fax:262-284-1172
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2486-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice