Healthcare Provider Details

I. General information

NPI: 1053886069
Provider Name (Legal Business Name): KATHRYN KUPCZYK RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2018
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 MICHIGAN AVE
STEVENS POINT WI
54481-0171
US

IV. Provider business mailing address

PO BOX 171
STEVENS POINT WI
54481-0171
US

V. Phone/Fax

Practice location:
  • Phone: 715-544-1180
  • Fax: 715-544-0845
Mailing address:
  • Phone: 715-544-1180
  • Fax: 715-544-0845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number100322216
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: