Provider Demographics
NPI:1710337423
Name:WICKLUND, KATRINA M (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:M
Last Name:WICKLUND
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 1:626 W CENTENNIAL AVE
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-2846
Mailing Address - Country:US
Mailing Address - Phone:417-358-9006
Mailing Address - Fax:
Practice Address - Street 1:626 W CENTENNIAL AVE
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MO
Practice Address - Zip Code:64836-2846
Practice Address - Country:US
Practice Address - Phone:417-358-9006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016018482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist