| Kenosha Dentist Llc | |
|
5455 Sheridan Rd Ste 201 Kenosha WI 53140-3752 | |
| (262) 244-0700 | |
| Not Available |
| Full Name | Kenosha Dentist Llc |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 5455 Sheridan Rd Ste 201, Kenosha, Wisconsin |
| Authorized Official Name and Position | Dominic Kaczynski (BUSINESS MANAGER) |
| Authorized Official Contact | 2622440700 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Kenosha Dentist Llc 5455 Sheridan Rd Ste 201 Kenosha WI 53140-3752 Ph: () - | Kenosha Dentist Llc 5455 Sheridan Rd Ste 201 Kenosha WI 53140-3752 Ph: (262) 244-0700 |
| NPI Number | 1205364197 |
|---|---|
| Provider Enumeration Date | 05/23/2017 |
| Last Update Date | 05/23/2017 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1205364197 | NPI | - | NPPES |
| 1699101477 | Medicaid | IL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | (* (Not Available)) | Primary |
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