Kenosha Dentist LLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

KENOSHA DENTIST LLC

Practice address

5455 Sheridan Rd Ste 201
Kenosha, WI 53140-3752

Phone

(262) 244-0700

NPI assigned

May 23, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dominic Kaczynski

Title

Business Manager

Phone

(262) 244-0700

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1495497600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1495497600000",
    "number": "1205364197",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5455 SHERIDAN RD STE 201",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531403752"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5455 SHERIDAN RD STE 201",
            "city": "KENOSHA",
            "state": "WI",
            "postal_code": "531403752",
            "telephone_number": "262-244-0700"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KENOSHA DENTIST LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-05-23",
        "last_updated": "2017-05-23",
        "status": "A",
        "authorized_official_last_name": "KACZYNSKI",
        "authorized_official_first_name": "DOMINIC",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "262-244-0700"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1699101477",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kenosha County Department of Human Services
• Kenosha County Department of Human Services
• Kenosha County Div of Public Health
• Kenosha County Division of Health
• Kenosha County Scout Leaders Rescue Squad, Inc (Scout Leaders Rescue Squad, Inc)
• Kenosha Digestive Health Center LLC
• Kenosha Emergency Physicians, LLC
• Kenosha Family Dentistry
• Kenosha Family Practice, S.C.
• Kenosha Family Vision Care LLC (Regner Family Vision Clinic)

• General Practice Dentistry in Kenosha, WI
• Providers in Kenosha, WI by specialty
• General Practice Dentistry in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 23, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.