Basic Information
| Provider Information | |||||||||
| NPI: | 1861599870 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHADRICK | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 W BELTLINE HWY | ||||||||
| Address2: | STE.120 | ||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537134226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084435500 | ||||||||
| FaxNumber: | 6084411981 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 E. FOUNTAIN ST. | ||||||||
| Address2: | |||||||||
| City: | DODGEVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535331749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6089355550 | ||||||||
| FaxNumber: | 6089355168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 5035-15 | WI | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 33750800 | 05 | WI | MEDICAID |