=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255063913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY MICHAEL KASIK DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2022
-----------------------------------------------------
Last Update Date | 06/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4071 LEE RD STE 260
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44128-2173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-861-6200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 99 W SAINT CLAIR AVE APT 1309
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44113-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-858-9155
-----------------------------------------------------
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 | 004532
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------