Healthcare Provider Details

I. General information

NPI: 1619176435
Provider Name (Legal Business Name): REBECCA M KUCERA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9075 TOWN CENTRE DR STE 130
BROADVIEW HEIGHTS OH
44147-4045
US

IV. Provider business mailing address

9075 TOWN CENTRE DR STE 130
BROADVIEW HEIGHTS OH
44147-4045
US

V. Phone/Fax

Practice location:
  • Phone: 440-838-1234
  • Fax: 440-838-0980
Mailing address:
  • Phone: 440-838-1234
  • Fax: 440-838-0980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30022569
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22569
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: