Provider Demographics
NPI:1871803361
Name:KOSITZKE, LISA M (RDH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KOSITZKE
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 1:1814 APPLETON RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1110
Mailing Address - Country:US
Mailing Address - Phone:920-731-7445
Mailing Address - Fax:920-731-7490
Practice Address - Street 1:1814 APPLETON RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1110
Practice Address - Country:US
Practice Address - Phone:920-731-7445
Practice Address - Fax:920-731-7490
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5601-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist