Provider Demographics
NPI:1659590453
Name:SCHWIEBERT, KENNETH A (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:SCHWIEBERT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:FL
Mailing Address - Zip Code:32696-2135
Mailing Address - Country:US
Mailing Address - Phone:352-528-4008
Mailing Address - Fax:352-528-6617
Practice Address - Street 1:173 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-2135
Practice Address - Country:US
Practice Address - Phone:352-528-4008
Practice Address - Fax:352-528-6617
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 86121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice