Provider Demographics
NPI:1376010868
Name:FODOR, SARAH KENNEDY (DDS)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:KENNEDY
Last Name:FODOR
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 1:2257 S WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-1315
Mailing Address - Country:US
Mailing Address - Phone:517-581-0059
Mailing Address - Fax:
Practice Address - Street 1:410 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086
Practice Address - Country:US
Practice Address - Phone:262-644-6951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1001966-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program