Healthcare Provider Details

I. General information

NPI: 1417260712
Provider Name (Legal Business Name): KASHEENA S HOLLIS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 W MAIN ST
SUN PRAIRIE WI
53590-1930
US

IV. Provider business mailing address

2901 W BELTLINE HWY SUITE 120
MADISON WI
53713-4226
US

V. Phone/Fax

Practice location:
  • Phone: 608-443-5482
  • Fax: 608-837-9134
Mailing address:
  • Phone: 608-443-5500
  • Fax: 608-441-2385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7188-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30-023210
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: