Healthcare Provider Details

I. General information

NPI: 1427061647
Provider Name (Legal Business Name): TERRY LEE KIPPA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MAIN ST
OSHKOSH WI
54902-6074
US

IV. Provider business mailing address

2958 OAKWOOD LN
OSHKOSH WI
54904-8437
US

V. Phone/Fax

Practice location:
  • Phone: 920-233-8882
  • Fax:
Mailing address:
  • Phone: 920-233-1509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5001751-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: