=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194306662
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT K THIELEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2021
-----------------------------------------------------
Last Update Date | 04/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 444 LIBERTY AVE
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15222-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-420-6502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20242 N 76TH WAY
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-6431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-255-4558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS042521
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------