MEDICARE: ANTHONY D KIESEL D.D.S

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	12012307A	IN
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1275920696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY D KIESEL D.D.S

Provider Business Mailing Address
First Line	:	621 DANVER LN
Second Line	:
City	:	BEECH GROVE
State	:	IN
Zip	:	46107-3328
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6150 E 82ND ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-1500
Country	:	US
Telephone Number	:	317-207-6480
Fax Number	:

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

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	09/25/2015

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