Healthcare Provider Details

I. General information

NPI: 1164683371
Provider Name (Legal Business Name): MARK A KUZMA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W MAIN ST SUITE B
GLASGOW KY
42141-1740
US

IV. Provider business mailing address

501 W MAIN ST SUITE B
GLASGOW KY
42141-1740
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-2638
  • Fax: 270-651-2638
Mailing address:
  • Phone: 270-651-2638
  • Fax: 270-651-2638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5888
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: