Provider Demographics
NPI:1568450393
Name:KIENTZ, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:KIENTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11449
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4005
Mailing Address - Country:US
Mailing Address - Phone:479-709-7445
Mailing Address - Fax:479-573-7849
Practice Address - Street 1:1500 DODSON AVE
Practice Address - Street 2:STE 180
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5182
Practice Address - Country:US
Practice Address - Phone:479-709-7445
Practice Address - Fax:479-573-7849
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4888207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105772001Medicaid
OK100076220AMedicaid
AR52870Medicare PIN
AR105772001Medicaid