Healthcare Provider Details

I. General information

NPI: 1629993662
Provider Name (Legal Business Name): DANIELA VILLAGOMEZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4006 WASHINGTON RD
KENOSHA WI
53144-4819
US

IV. Provider business mailing address

4006 WASHINGTON RD
KENOSHA WI
53144-4819
US

V. Phone/Fax

Practice location:
  • Phone: 262-771-3558
  • Fax:
Mailing address:
  • Phone: 262-656-0044
  • Fax: 262-649-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7002008-16
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: