Provider Demographics
NPI:1295148997
Name:KUMAR, SMITA
Entity type:Individual
Prefix:
First Name:SMITA
Middle Name:
Last Name:KUMAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2572 S 76TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-2476
Mailing Address - Country:US
Mailing Address - Phone:414-306-6420
Mailing Address - Fax:877-335-3684
Practice Address - Street 1:4915 WASHINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4221
Practice Address - Country:US
Practice Address - Phone:262-619-1949
Practice Address - Fax:877-335-3684
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7260-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice