Provider Demographics
NPI:1669439642
Name:TECLAW, JEROME MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:MICHAEL
Last Name:TECLAW
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 1:3959 N HARCOURT PL
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2445
Mailing Address - Country:US
Mailing Address - Phone:414-962-3972
Mailing Address - Fax:414-769-1130
Practice Address - Street 1:131 W LAYTON AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-5941
Practice Address - Country:US
Practice Address - Phone:414-483-3840
Practice Address - Fax:414-769-1130
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI027451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice