Provider Demographics
NPI:1487792305
Name:WASKO, KIM MARIE (DMD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:MARIE
Last Name:WASKO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 WILLOW ST
Mailing Address - Street 2:STE 2
Mailing Address - City:WINSTED
Mailing Address - State:CT
Mailing Address - Zip Code:06098
Mailing Address - Country:US
Mailing Address - Phone:860-379-4809
Mailing Address - Fax:860-379-4270
Practice Address - Street 1:140 WILLOW ST
Practice Address - Street 2:STE 2
Practice Address - City:WINSTED
Practice Address - State:CT
Practice Address - Zip Code:06098
Practice Address - Country:US
Practice Address - Phone:860-379-4809
Practice Address - Fax:860-379-4270
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0083601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice