Healthcare Provider Details

I. General information

NPI: 1124104393
Provider Name (Legal Business Name): LAWRENCE DAVID KISELICA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E DIAMOND ST
BUTLER PA
16001-5918
US

IV. Provider business mailing address

114 EAST DIAMOND ST
BUTLER PA
16001-5906
US

V. Phone/Fax

Practice location:
  • Phone: 724-282-6100
  • Fax: 724-282-7701
Mailing address:
  • Phone: 724-282-6100
  • Fax: 724-282-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS019428L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: