Organization
SOUTHPORT PERIODONTICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PATRICIA JENKINS (MANAGER)
(262) 654-6770
Entity
Organization
Contact information
Practice address
5021 WASHINGTON RD, KENOSHA, WI 53144
(262) 654-6770
(262) 654-6727
Mailing address
5021 WASHINGTON RD, KENOSHA, WI 53144-4292
(262) 654-6770
(262) 654-6727
Taxonomy
Speciality
Code
Description
License number
State
1223P0300X
Periodontics
Primary
—
—
Other
Enumeration date
05/22/2018
Last updated
05/22/2018
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