Provider Demographics
NPI:1326184961
Name:KLUG, KELLY SUE (RDH)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:SUE
Last Name:KLUG
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 1:1017 W GLEN OAKS LN
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3371
Mailing Address - Country:US
Mailing Address - Phone:262-241-4440
Mailing Address - Fax:262-241-3331
Practice Address - Street 1:1017 W GLEN OAKS LN
Practice Address - Street 2:SUITE 211
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3371
Practice Address - Country:US
Practice Address - Phone:262-241-4440
Practice Address - Fax:262-241-3331
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5801-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist