Provider Demographics
NPI:1649583857
Name:DR. KMIECK'S DENTAL HEALTH SERVICE INC
Entity Type:Organization
Organization Name:DR. KMIECK'S DENTAL HEALTH SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:KMIECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-888-9755
Mailing Address - Street 1:7057 W 130TH ST
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-7841
Mailing Address - Country:US
Mailing Address - Phone:440-888-9755
Mailing Address - Fax:440-888-8763
Practice Address - Street 1:7057 W 130TH ST
Practice Address - Street 2:
Practice Address - City:PARMA HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-7841
Practice Address - Country:US
Practice Address - Phone:440-888-9755
Practice Address - Fax:440-888-8763
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. KMIECK'S DENTAL HEALTH SERVICE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030029L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0467990Medicaid