Healthcare Provider Details

I. General information

NPI: 1861590960
Provider Name (Legal Business Name): MARY BETH KAISER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY BETH DIETSCHE

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 N 124TH ST STE F
WAUWATOSA WI
53222-2100
US

IV. Provider business mailing address

25 NEEDHAM ST
NEWTON MA
02461-1615
US

V. Phone/Fax

Practice location:
  • Phone: 414-535-8134
  • Fax: 414-535-8135
Mailing address:
  • Phone: 617-964-6681
  • Fax: 617-630-0141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number3509-016
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: