Healthcare Provider Details

I. General information

NPI: 1265589634
Provider Name (Legal Business Name): PAUL A KIESSLING DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 TUCKERTON ROAD
MEDFORD NJ
08055
US

IV. Provider business mailing address

308 TUCKERTON ROAD
MEDFORD NJ
08055
US

V. Phone/Fax

Practice location:
  • Phone: 609-654-2454
  • Fax: 609-654-6568
Mailing address:
  • Phone: 609-654-2454
  • Fax: 609-654-6568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9810
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: