MEDICARE: DR. JONATHAN W HIEMER D.M.D.

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	122300000X	Dentist	6188	KY
2	1223G0001X	General Practice Dentistry	6188	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y292	OTHER	KY	BCBS PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	469970	OTHER	KY	UNITED CONCORDIA
4	6342	OTHER	KY	PASSPORT PROVIDER NUMBER

General Provider Information

NPI Number	:	1487647863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN W HIEMER D.M.D.

Provider Business Mailing Address
First Line	:	6604 BARDSTOWN RD
Second Line	:	SUITE: B
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-3045
Country	:	US
Telephone Number	:	502-239-6850
Fax Number	:	502-239-3425

Provider Business Practice Location Address
First Line	:	6604 BARDSTOWN RD
Second Line	:	SUITE: B
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-3045
Country	:	US
Telephone Number	:	502-239-6850
Fax Number	:	502-239-3425

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

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	08/31/2015

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