Provider Demographics
NPI:1699251801
Name:LANGEVIN, KATHRYN (DMD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:LANGEVIN
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 1:15954 RIVERS EDGE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-7894
Mailing Address - Country:US
Mailing Address - Phone:715-634-2541
Mailing Address - Fax:
Practice Address - Street 1:108 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:BIRCHWOOD
Practice Address - State:WI
Practice Address - Zip Code:54817
Practice Address - Country:US
Practice Address - Phone:715-354-3369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001890122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist