Provider Demographics
NPI:1942699103
Name:GEISSLER-BALTS, NICOLE KATHLEEN (RDH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KATHLEEN
Last Name:GEISSLER-BALTS
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:N3104 1002ND ST
Mailing Address - Street 2:
Mailing Address - City:ELK MOUND
Mailing Address - State:WI
Mailing Address - Zip Code:54739-2011
Mailing Address - Country:US
Mailing Address - Phone:715-491-6056
Mailing Address - Fax:
Practice Address - Street 1:N3104 1002ND ST
Practice Address - Street 2:
Practice Address - City:ELK MOUND
Practice Address - State:WI
Practice Address - Zip Code:54739-2011
Practice Address - Country:US
Practice Address - Phone:715-491-6056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9972-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist