Healthcare Provider Details

I. General information

NPI: 1992978662
Provider Name (Legal Business Name): SARAH DITTMAN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W3275 WOLF RIVER ROAD
KESHENA WI
54135
US

IV. Provider business mailing address

PO BOX 970
KESHENA WI
54135-0970
US

V. Phone/Fax

Practice location:
  • Phone: 715-799-3361
  • Fax: 715-799-3099
Mailing address:
  • Phone: 715-799-3361
  • Fax: 715-799-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number9971
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: