Healthcare Provider Details

I. General information

NPI: 1528059979
Provider Name (Legal Business Name): DRS KANYUSIK WIEMERS & RUNCK PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E MAIN ST
MANKATO MN
56001-3501
US

IV. Provider business mailing address

120 E MAIN ST
MANKATO MN
56001-3501
US

V. Phone/Fax

Practice location:
  • Phone: 507-388-2989
  • Fax: 507-388-2985
Mailing address:
  • Phone: 507-388-2989
  • Fax: 507-388-2985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN S KANYUSIK
Title or Position: OWNER PARTNER PRESIDENT
Credential: DDS MS
Phone: 507-388-2989