| NPI | 1023565686 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KIMBERLY OLESEN President 262-497-5374 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 7238-15) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: WI 5001949-015) |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2016-09-01 |