Provider Demographics
NPI:1174652283
Name:KING, KEVIN SCOTT (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:SCOTT
Last Name:KING
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 1:423 FLINT CT.
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650
Mailing Address - Country:US
Mailing Address - Phone:608-779-1503
Mailing Address - Fax:
Practice Address - Street 1:1212 HORTON ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6372
Practice Address - Country:US
Practice Address - Phone:608-788-1090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice