Provider Demographics
NPI:1275920696
Name:KIESEL, ANTHONY D (DDS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:D
Last Name:KIESEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 DANVER LN
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-3328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6150 E 82ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1500
Practice Address - Country:US
Practice Address - Phone:317-207-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012307A1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program