Healthcare Provider Details

I. General information

NPI: 1518990167
Provider Name (Legal Business Name): KIM J PANSEGRAU DDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 OLD SAUK RD
MADISON WI
53717-2307
US

IV. Provider business mailing address

3296 SARACEN WAY
VERONA WI
53593-8010
US

V. Phone/Fax

Practice location:
  • Phone: 608-833-2060
  • Fax: 608-833-1737
Mailing address:
  • Phone: 608-821-0289
  • Fax: 608-833-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5144015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: