Organization
IDS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VICKY GILL (OFFICE MANAGER)
(847) 263-7668
Entity
Organization
Contact information
Practice address
5021 WASHINGTON RD, KENOSHA, WI 53144-4292
(262) 654-6770
Mailing address
5021 WASHINGTON RD, KENOSHA, WI 53144-4292
Taxonomy
Speciality
Code
Description
License number
State
1223E0200X
Endodontics
Primary
—
—
Other
Enumeration date
01/06/2020
Last updated
01/06/2020
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