Healthcare Provider Details

I. General information

NPI: 1952605230
Provider Name (Legal Business Name): MICHAEL P KISIL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2010
Last Update Date: 12/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 MAIN ST
HURON OH
44839-1620
US

IV. Provider business mailing address

119 MAIN ST
HURON OH
44839-1620
US

V. Phone/Fax

Practice location:
  • Phone: 419-433-5093
  • Fax: 419-433-7098
Mailing address:
  • Phone: 419-433-5093
  • Fax: 419-433-7098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30-15826
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: