MEDICARE: KINSER FAMILY DENTISTRY, LLC

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	19830	MI

General Provider Information

NPI Number	:	1255796892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINSER FAMILY DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	1315 E HOWARD CITY EDMORE RD
Second Line	:
City	:	EDMORE
State	:	MI
Zip	:	48829-9737
Country	:	US
Telephone Number	:	989-427-3430
Fax Number	:	989-427-1204

Provider Business Practice Location Address
First Line	:	1315 E HOWARD CITY EDMORE RD
Second Line	:
City	:	EDMORE
State	:	MI
Zip	:	48829-9737
Country	:	US
Telephone Number	:	989-427-3430
Fax Number	:	989-427-1204

Authorized Official
Title or Position	:	OWNER, DENTIST
Name	:	DR. SHAWN J KINSER
Credential	:	DDS, PHD
Telephone Number	:	616-894-7703

Provider Enumeration Date	:	12/28/2015
Last Update Date	:	12/28/2015

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