Provider Demographics
NPI:1265650741
Name:KROOK, KATHY JEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:JEAN
Last Name:KROOK
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 1:18 W MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53014-1300
Mailing Address - Country:US
Mailing Address - Phone:920-849-9518
Mailing Address - Fax:
Practice Address - Street 1:18 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:CHILTON
Practice Address - State:WI
Practice Address - Zip Code:53014-1300
Practice Address - Country:US
Practice Address - Phone:920-849-9518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41651223G0001X
LA38451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33696300Medicaid