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General NPI Number Information
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NPI Number | 1073828604
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Entity Type | Organization
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Legal Business Name | KITTLESON ORTHODONTICS, S.C.
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Dates
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Enumeration Date | 08/06/2010
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Last Update Date | 08/06/2010
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Provider Practice Location Address
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Address Line | 10521 N PORT WASHINGTON RD
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City | MEQUON
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State | WI
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Zip | 53092-5584
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Country | US
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Telephone | 262-241-3141
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Fax |
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Provider Business Mailing Address
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Address Line | 10521 N PORT WASHINGTON RD
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City | MEQUON
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State | WI
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Zip | 53092-5584
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Country | US
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Telephone | 262-241-3141
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Fax |
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | DR. JOHN CLAYTON KITTLESON
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Credential | D.D.S.
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Telephone | 262-241-3141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 4648-015
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License Number State | WI
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