Healthcare Provider Details

I. General information

NPI: 1366857146
Provider Name (Legal Business Name): KEVIN DANIEL CASTLEBERRY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 MILL ST
GREEN LAKE WI
54941
US

IV. Provider business mailing address

560 MILL ST
GREEN LAKE WI
54941-9527
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-6790
  • Fax:
Mailing address:
  • Phone: 920-294-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7284-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: