Provider Demographics
NPI:1437641214
Name:KOHL DENTAL LLC
Entity Type:Organization
Organization Name:KOHL DENTAL LLC
Other - Org Name:GARY J KOHL DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRENOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-833-2213
Mailing Address - Street 1:1 CORPORATE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-1725
Mailing Address - Country:US
Mailing Address - Phone:715-845-9297
Mailing Address - Fax:
Practice Address - Street 1:1 CORPORATE DR STE 104
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-1725
Practice Address - Country:US
Practice Address - Phone:715-845-9297
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty