Provider Demographics
NPI:1801198858
Name:KIM TRAN-WERTZ DDS MS LLC
Entity Type:Organization
Organization Name:KIM TRAN-WERTZ DDS MS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN-WERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:262-782-2300
Mailing Address - Street 1:12720 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4637
Mailing Address - Country:US
Mailing Address - Phone:262-782-2300
Mailing Address - Fax:262-782-2313
Practice Address - Street 1:12720 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4637
Practice Address - Country:US
Practice Address - Phone:262-782-2300
Practice Address - Fax:262-782-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4384-0151223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33770200Medicaid
WI000076983Medicare PIN