Provider Demographics
NPI:1871759985
Name:ULLOA, JOHN ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:ULLOA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-1525
Mailing Address - Country:US
Mailing Address - Phone:262-878-1500
Mailing Address - Fax:262-878-4782
Practice Address - Street 1:1680 15TH AVE
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-1525
Practice Address - Country:US
Practice Address - Phone:262-878-1500
Practice Address - Fax:262-878-4782
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4398122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391841902OtherTAX ID