Provider Demographics
NPI:1215570528
Name:TOSI, GRACE KIM (DDS)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:KIM
Last Name:TOSI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36078 RAVINIA PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-9204
Mailing Address - Country:US
Mailing Address - Phone:414-935-8293
Mailing Address - Fax:
Practice Address - Street 1:15375 W BLUEMOUND RD STE 150
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4008
Practice Address - Country:US
Practice Address - Phone:262-923-8731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002213122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist