Provider Demographics
NPI:1710185707
Name:KIENLE, MARK T (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:KIENLE
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 1:2501 24TH STREET
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5300
Mailing Address - Country:US
Mailing Address - Phone:309-786-1226
Mailing Address - Fax:309-786-0700
Practice Address - Street 1:2501 24TH STREET
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5300
Practice Address - Country:US
Practice Address - Phone:309-786-1226
Practice Address - Fax:309-786-0700
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL985080Medicare PIN