Provider Demographics
NPI:1346413028
Name:KESSEN, CONNIE (RDH)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:KESSEN
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:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:KESHENA
Mailing Address - State:WI
Mailing Address - Zip Code:54135-0970
Mailing Address - Country:US
Mailing Address - Phone:715-799-3361
Mailing Address - Fax:715-799-3099
Practice Address - Street 1:W3275 WOLF RIVER ROAD
Practice Address - Street 2:
Practice Address - City:KESHENA
Practice Address - State:WI
Practice Address - Zip Code:54135
Practice Address - Country:US
Practice Address - Phone:715-799-3361
Practice Address - Fax:715-799-3099
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6428124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33818000Medicaid