Provider Demographics
NPI:1891183257
Name:PRENTICE, TINA (RDH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:PRENTICE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDH
Mailing Address - Street 1:1730 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3201
Mailing Address - Country:US
Mailing Address - Phone:414-383-3220
Mailing Address - Fax:414-383-3363
Practice Address - Street 1:1730 S 13TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3201
Practice Address - Country:US
Practice Address - Phone:414-383-3220
Practice Address - Fax:414-383-3363
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6722-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist