Provider Demographics
NPI:1932203163
Name:KJOLSING, JEROME MARTIN (DDS)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:MARTIN
Last Name:KJOLSING
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017
Mailing Address - Country:US
Mailing Address - Phone:715-246-2555
Mailing Address - Fax:715-246-4361
Practice Address - Street 1:645 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017
Practice Address - Country:US
Practice Address - Phone:715-246-2555
Practice Address - Fax:715-246-4361
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5002198015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist