Healthcare Provider Details

I. General information

NPI: 1144458845
Provider Name (Legal Business Name): JASON MICHAEL KUESTER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 W BOONVILLE NEW HARMONY RD
EVANSVILLE IN
47725-9583
US

IV. Provider business mailing address

1331 W BOONVILLE NEW HARMONY RD
EVANSVILLE IN
47725-9583
US

V. Phone/Fax

Practice location:
  • Phone: 812-867-6428
  • Fax: 812-867-7494
Mailing address:
  • Phone: 812-867-6428
  • Fax: 812-867-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011322-A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: