Provider Demographics
NPI:1861590960
Name:KAISER, MARY BETH (RDH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:KAISER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:DIETSCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 NEEDHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1615
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:617-630-0141
Practice Address - Street 1:3720 N 124TH ST STE F
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2100
Practice Address - Country:US
Practice Address - Phone:414-535-8134
Practice Address - Fax:414-535-8135
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3509-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist