Provider Demographics
NPI:1144298266
Name:MIELKE, TIMOTHY R (DDS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:MIELKE
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 1:534 CRESCENT CT
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3856
Mailing Address - Country:US
Mailing Address - Phone:414-257-3585
Mailing Address - Fax:
Practice Address - Street 1:2600 N MAYFAIR RD
Practice Address - Street 2:SUITE 750
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1309
Practice Address - Country:US
Practice Address - Phone:414-257-3366
Practice Address - Fax:414-258-1390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001477015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist