MEDICARE: DR. JOHN IHOR KIS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	033482	CA

General Provider Information

NPI Number	:	1174621213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN IHOR KIS DDS

Provider Business Mailing Address
First Line	:	148 30TH AVE
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-2713
Country	:	US
Telephone Number	:	650-345-1773
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 SOUTHGATE AVE STE 210
Second Line	:
City	:	DALY CITY
State	:	CA
Zip	:	94015-2231
Country	:	US
Telephone Number	:	650-756-0938
Fax Number	:	650-756-1915

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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