Provider Demographics
NPI:1073828604
Name:KITTLESON ORTHODONTICS, S.C.
Entity Type:Organization
Organization Name:KITTLESON ORTHODONTICS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:KITTLESON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-241-3141
Mailing Address - Street 1:10521 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5584
Mailing Address - Country:US
Mailing Address - Phone:262-241-3141
Mailing Address - Fax:
Practice Address - Street 1:10521 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5584
Practice Address - Country:US
Practice Address - Phone:262-241-3141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4648-0151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty