Provider Demographics
NPI:1881848539
Name:WILSON, KAY MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:MARIE
Last Name:WILSON
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 1:600 SHELL CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:MONONG
Mailing Address - State:WI
Mailing Address - Zip Code:54859
Mailing Address - Country:US
Mailing Address - Phone:715-934-2224
Mailing Address - Fax:715-934-5440
Practice Address - Street 1:15910 W COMPANY LAKE ROAD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843
Practice Address - Country:US
Practice Address - Phone:715-934-2224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001787-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist