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General NPI Number Information
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NPI Number | 1982194700
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Entity Type | Individual
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Provider Name | DIANE COLETTE KOTHERA RDH
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Gender | Female
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Dates
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Enumeration Date | 05/16/2018
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Last Update Date | 05/16/2018
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Provider Practice Location Address
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Address Line | 2906 S 20TH ST
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City | MILWAUKEE
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State | WI
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Zip | 53215-3732
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Country | US
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Telephone | 414-897-5193
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Fax |
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Provider Business Mailing Address
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Address Line | 311 E ERIE ST UNIT 317
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City | MILWAUKEE
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State | WI
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Zip | 53202-6046
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Country | US
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Telephone | 414-379-2593
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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 | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 5122-16
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License Number State | WI
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