Provider Demographics
NPI:1558017426
Name:KEWASKUM FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KEWASKUM FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLASINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-626-2119
Mailing Address - Street 1:1204 FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:KEWASKUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040-8954
Mailing Address - Country:US
Mailing Address - Phone:262-626-2119
Mailing Address - Fax:
Practice Address - Street 1:1204 FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:KEWASKUM
Practice Address - State:WI
Practice Address - Zip Code:53040-8954
Practice Address - Country:US
Practice Address - Phone:262-626-2119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty