Healthcare Provider Details

I. General information

NPI: 1083826895
Provider Name (Legal Business Name): VALI KIAIE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 05/21/2022
Certification Date: 05/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 MAIN ST STE 200
BELGIUM WI
53004-9715
US

IV. Provider business mailing address

171 MAIN ST STE 200
BELGIUM WI
53004-9715
US

V. Phone/Fax

Practice location:
  • Phone: 262-285-3408
  • Fax: 262-285-4025
Mailing address:
  • Phone: 262-285-3408
  • Fax: 262-285-4025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number350415
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: