Provider Demographics
NPI:1366857146
Name:CASTLEBERRY, KEVIN DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DANIEL
Last Name:CASTLEBERRY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 MILL ST
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-9527
Mailing Address - Country:US
Mailing Address - Phone:920-294-6790
Mailing Address - Fax:
Practice Address - Street 1:560 MILL ST
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941
Practice Address - Country:US
Practice Address - Phone:920-294-6790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7284-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice