Healthcare Provider Details

I. General information

NPI: 1982194700
Provider Name (Legal Business Name): DIANE COLETTE KOTHERA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 S 20TH ST
MILWAUKEE WI
53215-3732
US

IV. Provider business mailing address

311 E ERIE ST UNIT 317
MILWAUKEE WI
53202-6046
US

V. Phone/Fax

Practice location:
  • Phone: 414-897-5193
  • Fax:
Mailing address:
  • Phone: 414-379-2593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5122-16
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: