Provider Demographics
NPI:1962506964
Name:WILTSE, LUCIANA MIRANDA (DDS, MS)
Entity Type:Individual
Prefix:
First Name:LUCIANA
Middle Name:MIRANDA
Last Name:WILTSE
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:LUCIANA
Other - Middle Name:MIRANDA
Other - Last Name:VAN WESTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12888 W. BLUEMOUND RD.
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122
Mailing Address - Country:US
Mailing Address - Phone:262-439-8233
Mailing Address - Fax:262-439-8246
Practice Address - Street 1:12888 W. BLUEMOUND RD.
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122
Practice Address - Country:US
Practice Address - Phone:262-439-8233
Practice Address - Fax:262-439-8246
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081911223X0400X
WI6102-151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics