Provider Demographics
NPI:1770169880
Name:REZBA, KATHLEEN A (RDH)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:REZBA
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 1:12112 FISHERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CATO
Mailing Address - State:WI
Mailing Address - Zip Code:54230-8026
Mailing Address - Country:US
Mailing Address - Phone:920-901-3740
Mailing Address - Fax:
Practice Address - Street 1:12112 FISHERVILLE RD
Practice Address - Street 2:
Practice Address - City:CATO
Practice Address - State:WI
Practice Address - Zip Code:54230-8026
Practice Address - Country:US
Practice Address - Phone:920-901-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6669-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist