Organization
KENOSHA DENTIST LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DOMINIC KACZYNSKI (BUSINESS MANAGER)
(262) 244-0700
Entity
Organization
Contact information
Practice address
5455 SHERIDAN RD STE 201, KENOSHA, WI 53140-3752
(262) 244-0700
Mailing address
5455 SHERIDAN RD STE 201, KENOSHA, WI 53140-3752
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1699101477
—
IL
Enumeration date
05/23/2017
Last updated
05/23/2017
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