Healthcare Provider Details

I. General information

NPI: 1316978026
Provider Name (Legal Business Name): KRISTIN LYNN OSGOOD KOTLEWSKI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN L OSGOOD

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10155 WASHINGTON AVE
STURTEVANT WI
53177-1645
US

IV. Provider business mailing address

4554 W ALESCI DR
FRANKLIN WI
53132-8170
US

V. Phone/Fax

Practice location:
  • Phone: 262-884-3011
  • Fax: 262-664-7799
Mailing address:
  • Phone: 414-423-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4902
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4902
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: