Kali Rose Disterhoft

Primary specialty

DentistTaxonomy code 122300000X

License

1002654-15 Issued in WI

Practice address

33 E Waldo Blvd
Manitowoc, WI 54220-2900

Phone

(920) 682-0115

NPI assigned

Jul 6, 2021

Sex

Female

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• MDC Manitowoc SC

  • General Practice Dentistry
  • Manitowoc, WI
  • NPI 1598176547
  NPD (past)

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

{
    "created_epoch": "1625529600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1627171200000",
    "number": "1962073577",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "622 PENNSYLVANIA AVE UNIT 504",
            "city": "SHEBOYGAN",
            "state": "WI",
            "postal_code": "530814662"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "33 E WALDO BLVD",
            "city": "MANITOWOC",
            "state": "WI",
            "postal_code": "542202900",
            "telephone_number": "920-682-0115"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DISTERHOFT",
        "first_name": "KALI",
        "middle_name": "ROSE",
        "name_prefix": "Dr.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-07-06",
        "last_updated": "2021-07-25",
        "certification_date": "2021-07-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IA",
            "license": "DDS-09919",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "WI",
            "license": "1002654-15",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Holly Edna Dewane, RPH
• Diana Lampsa MDSC
• Corey Michael Dietz, PHARMD
• Denise Marie Dill, MS
• Carl Alan Diraimondo, M.D.
• Jenna Mae Domino, APNP
• Donald James Domrath, O.D.
• Julie Donahue
• Michael David Dorcas, RPH
• Katherine Dorner, M.S., CCC-SLP

• Dentist in Manitowoc, WI
• Providers in Manitowoc, WI by specialty
• Dentist in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2021; 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.