MEDICARE: DR. STANLEY WARREN KACZKOWSKI 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	WV2189	WV

General Provider Information

NPI Number	:	1962502831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STANLEY WARREN KACZKOWSKI DDS

Provider Business Mailing Address
First Line	:	5376 BIG TYLER RD
Second Line	:
City	:	CROSS LANES
State	:	WV
Zip	:	25313-1059
Country	:	US
Telephone Number	:	304-776-2223
Fax Number	:	304-776-2225

Provider Business Practice Location Address
First Line	:	5376 BIG TYLER RD
Second Line	:
City	:	CROSS LANES
State	:	WV
Zip	:	25313-1059
Country	:	US
Telephone Number	:	304-776-2223
Fax Number	:	304-776-2225

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. STANLEY WARREN KACZKOWSKI DDS” Practice Location

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