Healthcare Provider Details

I. General information

NPI: 1366597197
Provider Name (Legal Business Name): KIERSZ DENTISTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 MARSHALL DR
SAINT ROBERT MO
65584-5603
US

IV. Provider business mailing address

441 MARSHALL DR
SAINT ROBERT MO
65584-5603
US

V. Phone/Fax

Practice location:
  • Phone: 573-336-5599
  • Fax: 573-336-4809
Mailing address:
  • Phone: 573-336-5599
  • Fax: 573-336-4809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number016051
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number015882
License Number StateMO

VIII. Authorized Official

Name: DR. JEREMY C KIERSZ
Title or Position: DENTIST
Credential: DDS
Phone: 573-336-5599