Provider Demographics
NPI:1083761191
Name:KUJAK, DANIEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:KUJAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4102
Mailing Address - Country:US
Mailing Address - Phone:608-784-4063
Mailing Address - Fax:608-782-5757
Practice Address - Street 1:1200 MAIN ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4102
Practice Address - Country:US
Practice Address - Phone:608-784-4063
Practice Address - Fax:608-782-5757
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5352-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391191322OtherFED TAX ID