Healthcare Provider Details

I. General information

NPI: 1952785271
Provider Name (Legal Business Name): VRISIIS KOFINA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W WISCONSIN AVE
MILWAUKEE WI
53233-2186
US

IV. Provider business mailing address

1801 W WISCONSIN AVE
MILWAUKEE WI
53233-2186
US

V. Phone/Fax

Practice location:
  • Phone: 414-288-5902
  • Fax:
Mailing address:
  • Phone: 414-288-5902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number18301-875
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: