Provider Demographics
NPI:1801987631
Name:GARDOCKI, THERESA (DENTIS)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:GARDOCKI
Suffix:
Gender:F
Credentials:DENTIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PLEASANT OAK DR
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-3648
Mailing Address - Country:US
Mailing Address - Phone:608-835-3388
Mailing Address - Fax:608-835-3386
Practice Address - Street 1:600 PLEASANT OAK DR
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-3648
Practice Address - Country:US
Practice Address - Phone:608-835-3388
Practice Address - Fax:608-835-3386
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3054122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33458500Medicaid