Provider Demographics
NPI:1760102768
Name:BREA, KAYLEE KASSANDRA (DMD)
Entity Type:Individual
Prefix:
First Name:KAYLEE
Middle Name:KASSANDRA
Last Name:BREA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ROCKY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:706 S GAMMON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1302
Practice Address - Country:US
Practice Address - Phone:608-720-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI600107515122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist