Provider Demographics
NPI:1245355460
Name:KIM A GOWEY DDS LTD
Entity type:Organization
Organization Name:KIM A GOWEY DDS LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOWEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-748-4432
Mailing Address - Street 1:PO BOX 389
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-0389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1034 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1310
Practice Address - Country:US
Practice Address - Phone:715-748-4432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001790015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty