=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669959995
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOHANAMURALIKRISHNA KASAM DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2018
-----------------------------------------------------
Last Update Date | 07/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3113 S 13TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53215-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-477-5665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8716 S WOOD CREEK DR APT 2
-----------------------------------------------------
City | OAK CREEK
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53154-7507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-217-9774
-----------------------------------------------------
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 | 100189115
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------