Healthcare Provider Details

I. General information

NPI: 1336350412
Provider Name (Legal Business Name): HEATHER MARIE KINNUNEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 OSTERMANN DR
TURTLE LAKE WI
54889-9191
US

IV. Provider business mailing address

53272 CO RD D
GRAND VIEW WI
54839
US

V. Phone/Fax

Practice location:
  • Phone: 715-986-2020
  • Fax:
Mailing address:
  • Phone: 715-763-3118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number6401-016
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: