Healthcare Provider Details

I. General information

NPI: 1174614168
Provider Name (Legal Business Name): GERALD J KAZMERSKI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 04/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 WYOMING AVE SECOND FLOOR, DENTAL OFFICES
SCRANTON PA
18509-3023
US

IV. Provider business mailing address

SCRANTON PRIMARY HEALTH CARE CENTER-DENTAL 959 WYOMING AVENUE, SECOND FLOOR
SCRANTON PA
18509
US

V. Phone/Fax

Practice location:
  • Phone: 570-504-0882
  • Fax: 570-504-0859
Mailing address:
  • Phone: 570-504-0882
  • Fax: 570-504-0859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDS017739L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1010505830003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: