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General NPI Number Information
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NPI Number | 1558017426
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Entity Type | Organization
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Legal Business Name | KEWASKUM FAMILY DENTISTRY
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Dates
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Enumeration Date | 03/01/2022
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 1721 FOND DU LAC AVE
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City | KEWASKUM
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State | WI
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Zip | 53040-8954
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Country | US
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Telephone | 262-626-2119
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Fax |
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Provider Business Mailing Address
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Address Line | 1204 FOND DU LAC AVE
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City | KEWASKUM
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State | WI
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Zip | 53040-8954
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Country | US
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Telephone | 262-626-2119
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. SARA KLASINSKI
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Credential | DDS
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Telephone | 262-626-2119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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