MEDICARE: KEVIN KNIERIM

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	30-023015	OH

General Provider Information

NPI Number	:	1841420585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN KNIERIM

Provider Business Mailing Address
First Line	:	1000 REGENCY CT
Second Line	:	101
City	:	TOLEDO
State	:	OH
Zip	:	43623-3091
Country	:	US
Telephone Number	:	419-473-2728
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 REGENCY CT
Second Line	:	101
City	:	TOLEDO
State	:	OH
Zip	:	43623-3091
Country	:	US
Telephone Number	:	419-473-2728
Fax Number	:

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

Provider Enumeration Date	:	07/15/2009
Last Update Date	:	07/15/2009

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