Provider Demographics
NPI:1871693747
Name:DENTINO, ANDREW (DDS, PHD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:DENTINO
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1100
Mailing Address - Country:US
Mailing Address - Phone:414-566-6400
Mailing Address - Fax:414-566-3900
Practice Address - Street 1:555 S 108TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-1100
Practice Address - Country:US
Practice Address - Phone:414-566-6400
Practice Address - Fax:414-566-3900
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4463-0151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics