Provider Demographics
NPI:1104954437
Name:KVANBECK, THOMAS J (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:KVANBECK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:16 E BAYFIELD ST.
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891-0265
Mailing Address - Country:US
Mailing Address - Phone:715-373-2612
Mailing Address - Fax:
Practice Address - Street 1:16 E BAYFIELD ST
Practice Address - Street 2:16 E BAYFIELD ST
Practice Address - City:WASHBURN
Practice Address - State:WI
Practice Address - Zip Code:54891-4401
Practice Address - Country:US
Practice Address - Phone:715-373-2612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2784122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33427800Medicaid