MEDICARE: DR. EVELYN KATRINA HAUSER-FREDERICK D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5002024-015	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5002024-015	OTHER	WI	STATE DENTAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1356554851	OTHER		NPI TYPE II

General Provider Information

NPI Number	:	1639583610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EVELYN KATRINA HAUSER-FREDERICK D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 266
Second Line	:	137 E MAIN ST.
City	:	GILLETT
State	:	WI
Zip	:	54124-0266
Country	:	US
Telephone Number	:	920-855-2155
Fax Number	:	920-855-2639

Provider Business Practice Location Address
First Line	:	137 E MAIN ST
Second Line	:
City	:	GILLETT
State	:	WI
Zip	:	54124-9386
Country	:	US
Telephone Number	:	920-855-2155
Fax Number	:	920-855-2639

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2014
Last Update Date	:	06/17/2014

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