MEDICARE: DR. KMIECK'S DENTAL HEALTH SERVICE INC

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	122300000X	Dentist	DS030029L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649583857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. KMIECK'S DENTAL HEALTH SERVICE INC

Provider Business Mailing Address
First Line	:	7057 W 130TH ST
Second Line	:
City	:	PARMA HEIGHTS
State	:	OH
Zip	:	44130-7841
Country	:	US
Telephone Number	:	440-888-9755
Fax Number	:	440-888-8763

Provider Business Practice Location Address
First Line	:	7057 W 130TH ST
Second Line	:
City	:	PARMA HEIGHTS
State	:	OH
Zip	:	44130-7841
Country	:	US
Telephone Number	:	440-888-9755
Fax Number	:	440-888-8763

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH THOMAS KMIECK
Credential	:	DDS
Telephone Number	:	440-888-9755

Provider Enumeration Date	:	07/16/2010
Last Update Date	:	07/16/2010

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