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General NPI Number Information
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NPI Number | 1962010249
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Entity Type | Individual
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Provider Name | EMILY ROSE NESIC DMD
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Gender | Female
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Dates
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Enumeration Date | 07/22/2020
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Last Update Date | 10/25/2021
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Provider Practice Location Address
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Address Line | 580 BROAD ST
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City | LAKE GENEVA
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State | WI
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Zip | 53147-1420
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Country | US
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Telephone | 262-248-2773
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Fax |
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Provider Business Mailing Address
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Address Line | 570 SOUTHWIND DR UNIT 207
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City | LAKE GENEVA
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State | WI
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Zip | 53147-4713
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Country | US
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Telephone | 815-830-5729
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 100237915
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License Number State | WI
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