Provider Demographics
NPI:1013937499
Name:MARQUETTE UNIVERSITY
Entity Type:Organization
Organization Name:MARQUETTE UNIVERSITY
Other - Org Name:MARQUETTE UNIVERSITY SCHOOL OF DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSOCIATE DEAN
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CREAMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-288-7485
Mailing Address - Street 1:PO BOX 1881
Mailing Address - Street 2:SUITE 145 B
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1881
Mailing Address - Country:US
Mailing Address - Phone:414-288-5902
Mailing Address - Fax:414-288-8361
Practice Address - Street 1:1801 W WISCONSIN AVE
Practice Address - Street 2:SUITE 145 B
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2186
Practice Address - Country:US
Practice Address - Phone:414-288-5902
Practice Address - Fax:414-288-8361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33360600Medicaid
77612Medicare ID - Type Unspecified