Healthcare Provider Details

I. General information

NPI: 1578117289
Provider Name (Legal Business Name): NATHALIE R GUZMAN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 S 13TH ST
MILWAUKEE WI
53204-3201
US

IV. Provider business mailing address

1730 S 13TH ST
MILWAUKEE WI
53204-3201
US

V. Phone/Fax

Practice location:
  • Phone: 414-383-3220
  • Fax: 411-383-3363
Mailing address:
  • Phone: 414-383-3220
  • Fax: 411-383-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1002988
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: