Provider Demographics
NPI:1447699475
Name:ARCHAMBEAU, KELLY N (RDH)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:N
Last Name:ARCHAMBEAU
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 1:15910 W COMPANY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-5320
Mailing Address - Country:US
Mailing Address - Phone:715-934-2224
Mailing Address - Fax:
Practice Address - Street 1:15910 W COMPANY LAKE RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5320
Practice Address - Country:US
Practice Address - Phone:715-934-2224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11392-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist