Provider Demographics
NPI:1235313339
Name:BRIAN L. KRESEVIC, DDS, LLC
Entity Type:Organization
Organization Name:BRIAN L. KRESEVIC, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LUDWIG
Authorized Official - Last Name:KRESEVIC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-466-4884
Mailing Address - Street 1:184 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:OH
Mailing Address - Zip Code:44041-1805
Mailing Address - Country:US
Mailing Address - Phone:440-466-4884
Mailing Address - Fax:440-466-0636
Practice Address - Street 1:184 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-1805
Practice Address - Country:US
Practice Address - Phone:440-466-4884
Practice Address - Fax:440-466-0636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH199861223G0001X
OH200271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty