Healthcare Provider Details

I. General information

NPI: 1780205088
Provider Name (Legal Business Name): KELSEY MP HOSTETLER DDS, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 S MAIN ST
VERONA WI
53593-1470
US

IV. Provider business mailing address

6797 HORSESHOE BND
VERONA WI
53593-9211
US

V. Phone/Fax

Practice location:
  • Phone: 608-845-6612
  • Fax:
Mailing address:
  • Phone: 608-448-5056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KELSEY MARIE PATTON HOSTETLER
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 608-448-5056