Provider Demographics
NPI:1578670279
Name:KOHL, GARY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:KOHL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 CORPORATE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-1722
Mailing Address - Country:US
Mailing Address - Phone:715-845-9297
Mailing Address - Fax:715-843-6972
Practice Address - Street 1:1 CORPORATE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-1722
Practice Address - Country:US
Practice Address - Phone:715-845-9297
Practice Address - Fax:715-843-6972
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001470-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33648700Medicaid