Healthcare Provider Details

I. General information

NPI: 1114051687
Provider Name (Legal Business Name): KRISTEN D SKOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 SCHNEIDER AVE SE SUITE 1
MENOMONIE WI
54751-2820
US

IV. Provider business mailing address

3101 SCHNEIDER AVE SE SUITE 1
MENOMONIE WI
54751-2820
US

V. Phone/Fax

Practice location:
  • Phone: 715-233-1400
  • Fax:
Mailing address:
  • Phone: 715-233-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5206
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: