Provider Demographics
NPI:1457388084
Name:LITZOW, DAVE JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVE
Middle Name:JOHN
Last Name:LITZOW
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 E JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935
Mailing Address - Country:US
Mailing Address - Phone:920-924-9090
Mailing Address - Fax:920-921-0800
Practice Address - Street 1:545 E. JOHNSON ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-924-9090
Practice Address - Fax:920-921-0800
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000183-0151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33658400Medicaid