Healthcare Provider Details

I. General information

NPI: 1508949082
Provider Name (Legal Business Name): GARY L KAEFER DDS SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 SOUTH PINE ST
GRANTSBURG WI
54840
US

IV. Provider business mailing address

302 SOUTH PINE ST
GRANTSBURG WI
54840
US

V. Phone/Fax

Practice location:
  • Phone: 715-463-2882
  • Fax: 715-463-2885
Mailing address:
  • Phone: 715-463-2882
  • Fax: 715-463-2885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5001913
License Number StateWI

VIII. Authorized Official

Name: DR. GARY L KAEFER
Title or Position: OWNER
Credential: DDS
Phone: 715-463-2882