Provider Demographics
NPI:1275295040
Name:HOMAN, KATHLEEN (RDH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:HOMAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N9261 COMSTOCK RD
Mailing Address - Street 2:
Mailing Address - City:PARDEEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53954-9750
Mailing Address - Country:US
Mailing Address - Phone:608-988-6472
Mailing Address - Fax:
Practice Address - Street 1:964 COUNTY ROAD T
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:WI
Practice Address - Zip Code:53559-9735
Practice Address - Country:US
Practice Address - Phone:608-988-6472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10158124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist