=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184953325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIZIOR & YOUNG ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2009
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2005 SAINT CHARLES ST SUITE 3
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47546-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-634-2040
-----------------------------------------------------
Fax | 812-482-7405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2005 SAINT CHARLES ST SUITE 3
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47546-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-634-2040
-----------------------------------------------------
Fax | 812-482-7405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN W KIZIOR
-----------------------------------------------------
Credential | DDS.,MSD
-----------------------------------------------------
Telephone | 812-634-2040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 12010318A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------