Provider Demographics
NPI:1518990167
Name:PANSEGRAU, KIM J (DDS MD)
Entity Type:Individual
Prefix:MR
First Name:KIM
Middle Name:J
Last Name:PANSEGRAU
Suffix:
Gender:M
Credentials:DDS MD
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Mailing Address - Street 1:3296 SARACEN WAY
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-8010
Mailing Address - Country:US
Mailing Address - Phone:608-821-0289
Mailing Address - Fax:608-833-1787
Practice Address - Street 1:7007 OLD SAUK RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2307
Practice Address - Country:US
Practice Address - Phone:608-833-2060
Practice Address - Fax:608-833-1737
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI51440151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33755700Medicaid
WI33755700Medicaid