Healthcare Provider Details

I. General information

NPI: 1306297288
Provider Name (Legal Business Name): BASIA M KOWALIK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1076 BEDFORD CT
RACINE WI
53406-7010
US

IV. Provider business mailing address

1076 BEDFORD CT
RACINE WI
53406-7010
US

V. Phone/Fax

Practice location:
  • Phone: 414-861-1237
  • Fax:
Mailing address:
  • Phone: 414-861-1237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3505
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: