Basic Information
| Provider Information | |||||||||
| NPI: | 1184690489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WUKICH | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | KENT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142662600 | ||||||||
| FaxNumber: | 2145902773 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 INWOOD RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753908883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146453300 | ||||||||
| FaxNumber: | 2946453301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | R0524 | TX | N | Other Service Providers | Specialist | 207XX0004X | R0524 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001239430 | 05 | TX | MEDICAID |