Healthcare Provider Details

I. General information

NPI: 1982192316
Provider Name (Legal Business Name): NICOLE MARIE KUJAWA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W WISCONSIN AVE
MILWAUKEE WI
53233
US

IV. Provider business mailing address

1801 W WISCONSIN AVE
MILWAUKEE WI
53233-2186
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-6790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.031723
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License Number019.031723
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: