Provider Demographics
NPI:1992379457
Name:COLLELO, KATELYN (DDS)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:COLLELO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-2315
Mailing Address - Country:US
Mailing Address - Phone:715-297-1209
Mailing Address - Fax:
Practice Address - Street 1:227071 HUMMINGBIRD RD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-3332
Practice Address - Country:US
Practice Address - Phone:715-845-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002598-151223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral Practice