=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629968235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAIGE KRISTINE TIERNEY DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2025
-----------------------------------------------------
Last Update Date | 07/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 TRI PARK WAY
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54914-1661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-882-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 329 WHITE CEDAR PKWY APT I
-----------------------------------------------------
City | KIMBERLY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54136-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-882-5500
-----------------------------------------------------
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 | 6001824-15
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------