Provider Demographics
NPI:1639583610
Name:HAUSER-FREDERICK, EVELYN KATRINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:KATRINA
Last Name:HAUSER-FREDERICK
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:PO BOX 266
Mailing Address - Street 2:137 E MAIN ST.
Mailing Address - City:GILLETT
Mailing Address - State:WI
Mailing Address - Zip Code:54124-0266
Mailing Address - Country:US
Mailing Address - Phone:920-855-2155
Mailing Address - Fax:920-855-2639
Practice Address - Street 1:137 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GILLETT
Practice Address - State:WI
Practice Address - Zip Code:54124-9386
Practice Address - Country:US
Practice Address - Phone:920-855-2155
Practice Address - Fax:920-855-2639
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5002024-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5002024-015OtherSTATE DENTAL LICENSE
WI33374500Medicaid
1356554851OtherNPI TYPE II