=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396058160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAULA ANN REESE RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2010
-----------------------------------------------------
Last Update Date | 07/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 E VETERANS ST
-----------------------------------------------------
City | TOMAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54660-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-372-1720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 616 S RUSK AVE
-----------------------------------------------------
City | VIROQUA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54665-2037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-637-3713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 1001118-16
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------