Provider Demographics
NPI:1336764281
Name:JASPER, KAITLIN ANNE (DDS)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ANNE
Last Name:JASPER
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 1:1001 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-2500
Mailing Address - Country:US
Mailing Address - Phone:414-764-6760
Mailing Address - Fax:
Practice Address - Street 1:1001 MADISON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53172-2500
Practice Address - Country:US
Practice Address - Phone:414-764-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10023511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty