Provider Demographics
NPI:1720337157
Name:AMELSE, DONNA JEAN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:JEAN
Last Name:AMELSE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:DONNA
Other - Middle Name:JEAN
Other - Last Name:CASKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:S5465 COUNTY ROAD SS
Mailing Address - Street 2:
Mailing Address - City:VIOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54664-8035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 PACKARD ST
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:WI
Practice Address - Zip Code:54670-7730
Practice Address - Country:US
Practice Address - Phone:608-343-6684
Practice Address - Fax:608-435-6905
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10873-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist