=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144956053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHIVANI KUSHWAHA DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2022
-----------------------------------------------------
Last Update Date | 07/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2831 NATIONAL DR
-----------------------------------------------------
City | ONALASKA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54650-6703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-781-9092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41016 STATE HIGHWAY 30
-----------------------------------------------------
City | RUSHFORD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55971-5157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-202-4807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 600104015
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------