MEDICARE: DR. JON T KOBLENSVIK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	14206	TX

General Provider Information

NPI Number	:	1386653939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON T KOBLENSVIK DDS

Provider Business Mailing Address
First Line	:	1735 KELLER SPRINGS RD
Second Line	:	SUITE 204
City	:	CARROLLTON
State	:	TX
Zip	:	75006-2962
Country	:	US
Telephone Number	:	972-245-3455
Fax Number	:	972-242-1686

Provider Business Practice Location Address
First Line	:	1735 KELLER SPRINGS RD
Second Line	:	SUITE 204
City	:	CARROLLTON
State	:	TX
Zip	:	75006-2962
Country	:	US
Telephone Number	:	972-245-3455
Fax Number	:	972-242-1686

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/26/2007

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