Healthcare Provider Details

I. General information

NPI: 1841623451
Provider Name (Legal Business Name): ANGELA K FITZPATRICK RDH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6831 53RD ST UNIT 146
KENOSHA WI
53144-3770
US

IV. Provider business mailing address

6831 53RD ST UNIT 146
KENOSHA WI
53144-3770
US

V. Phone/Fax

Practice location:
  • Phone: 262-818-1874
  • Fax:
Mailing address:
  • Phone: 262-818-1874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number9800-16
License Number StateWI

VIII. Authorized Official

Name: ANGELA K FITZPATRICK
Title or Position: DENTAL HYGIENIST
Credential: RDH
Phone: 262-818-1874