=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083020739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRANDEEP KAUR DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2014
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 519 N 17TH AVE
-----------------------------------------------------
City | WAUSAU
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54401-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-842-5459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151030 SAGE LN
-----------------------------------------------------
City | WAUSAU
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54401-5115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-509-5264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0030225
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 09239
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1001190
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------