Provider Demographics
NPI:1831275312
Name:SELMO, DON LOUIS (DDS)
Entity type:Individual
Prefix:DR
First Name:DON
Middle Name:LOUIS
Last Name:SELMO
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 1:3308 ROSALIND AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4918
Mailing Address - Country:US
Mailing Address - Phone:262-554-6955
Mailing Address - Fax:
Practice Address - Street 1:1320 S GREENBAY RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4406
Practice Address - Country:US
Practice Address - Phone:262-637-9371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000491-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38393900Medicaid