MEDICARE: DR. JON KLEVANSKY DMD

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	GA12590	GA

General Provider Information

NPI Number	:	1528180411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON KLEVANSKY DMD

Provider Business Mailing Address
First Line	:	3993 LAWRENCEVILLE HWY
Second Line	:	SUITE 100A
City	:	LILBURN
State	:	GA
Zip	:	30047-2831
Country	:	US
Telephone Number	:	770-921-1115
Fax Number	:	770-564-3856

Provider Business Practice Location Address
First Line	:	3993 LAWRENCEVILLE HWY
Second Line	:	SUITE 100A
City	:	LILBURN
State	:	GA
Zip	:	30047-2831
Country	:	US
Telephone Number	:	770-921-1115
Fax Number	:	770-564-3856

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

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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