Healthcare Provider Details

I. General information

NPI: 1396631982
Provider Name (Legal Business Name): KATHERINE SU DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 N FOND DU LAC AVE
CAMPBELLSPORT WI
53010-2787
US

IV. Provider business mailing address

130 N FOND DU LAC AVE
CAMPBELLSPORT WI
53010-2787
US

V. Phone/Fax

Practice location:
  • Phone: 920-533-8512
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6001848-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: