Healthcare Provider Details

I. General information

NPI: 1871669150
Provider Name (Legal Business Name): JOHN STEPHEN KANYUSIK DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/08/2007
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 Number7561
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: