Provider Demographics
NPI:1487812855
Name:TERRY L. KIPPA DDS SC
Entity type:Organization
Organization Name:TERRY L. KIPPA DDS SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:KORTHALS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-233-8882
Mailing Address - Street 1:600 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-6074
Mailing Address - Country:US
Mailing Address - Phone:920-233-8882
Mailing Address - Fax:920-303-2736
Practice Address - Street 1:600 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-6074
Practice Address - Country:US
Practice Address - Phone:920-233-8882
Practice Address - Fax:920-303-2736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-01
Last Update Date:2008-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4375-0151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty