MEDICARE: DR. DAVID BRUCE KIESER 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	122300000X	Dentist	4200	WI
2	122300000X	Dentist	4200-15	WI

General Provider Information

NPI Number	:	1821072794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID BRUCE KIESER D.D.S.

Provider Business Mailing Address
First Line	:	338 S DAKOTA AVE
Second Line	:
City	:	VANDENBERG AFB
State	:	CA
Zip	:	93437-6307
Country	:	US
Telephone Number	:	805-605-4085
Fax Number	:

Provider Business Practice Location Address
First Line	:	338 S DAKOTA AVE
Second Line	:
City	:	VANDENBERG AFB
State	:	CA
Zip	:	93437-6307
Country	:	US
Telephone Number	:	805-605-4085
Fax Number	:

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

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	05/06/2018

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