Provider Demographics
NPI:1790102143
Name:KUSSOW, ANGELA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:KUSSOW
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 W BELTLINE HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-4226
Mailing Address - Country:US
Mailing Address - Phone:608-443-5500
Mailing Address - Fax:608-441-2385
Practice Address - Street 1:103 E. FOUNTAIN ST.
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-1749
Practice Address - Country:US
Practice Address - Phone:608-935-5550
Practice Address - Fax:608-935-5168
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5616-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist