Healthcare Provider Details

I. General information

NPI: 1861847097
Provider Name (Legal Business Name): KIMBERLY CARMICHAEL D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6217 S PACKARD AVE
CUDAHY WI
53110-3096
US

IV. Provider business mailing address

406 LINDGREN LN
BELVIDERE IL
61008-7065
US

V. Phone/Fax

Practice location:
  • Phone: 414-764-5550
  • Fax: 414-764-9198
Mailing address:
  • Phone: 815-721-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1001312-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: