Provider Demographics
NPI:1336360973
Name:HERRICK, DEBORA ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEBORA
Middle Name:ANN
Last Name:HERRICK
Suffix:
Gender:F
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:W315 N7641 HYWY 83
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029
Mailing Address - Country:US
Mailing Address - Phone:262-966-7668
Mailing Address - Fax:262-966-3420
Practice Address - Street 1:W315 N7641 HYWY 83 PO87
Practice Address - Street 2:
Practice Address - City:NORTH LAKE
Practice Address - State:WI
Practice Address - Zip Code:53064-0087
Practice Address - Country:US
Practice Address - Phone:262-966-7668
Practice Address - Fax:262-966-3420
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0032061223G0001X
AZ64661223G0001X
AK11681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33800000OtherBADGERCARE
WI33800000Medicaid
WI33800000Medicaid