Provider Demographics
NPI:1528264819
Name:KITTLESON, RUSSELL THEODORE (DDS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:THEODORE
Last Name:KITTLESON
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 1:10521 N PORT WASHINGTON RD # 13W
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5584
Mailing Address - Country:US
Mailing Address - Phone:262-241-3142
Mailing Address - Fax:262-241-3634
Practice Address - Street 1:10521 N PORT WASHINGTON RD # 13W
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5584
Practice Address - Country:US
Practice Address - Phone:262-241-3142
Practice Address - Fax:262-241-3634
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4001404122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist