Provider Demographics
NPI:1992994339
Name:MARK J KNEEPKENS
Entity type:Organization
Organization Name:MARK J KNEEPKENS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KNEEPKENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-542-6170
Mailing Address - Street 1:601 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4918
Mailing Address - Country:US
Mailing Address - Phone:262-542-6170
Mailing Address - Fax:262-542-6194
Practice Address - Street 1:601 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4918
Practice Address - Country:US
Practice Address - Phone:262-542-6170
Practice Address - Fax:262-542-6194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI383-71200Medicaid