=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396413951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLIE FORD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2021
-----------------------------------------------------
Last Update Date | 08/31/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2848 COTTAGE GROVE RD
-----------------------------------------------------
City | COTTAGE GROVE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53527-8862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-839-6363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 725 SENECA PL
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53711-2950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-404-0604
-----------------------------------------------------
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 | 1002656-15
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------