Provider Demographics
NPI:1821072794
Name:KIESER, DAVID BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRUCE
Last Name:KIESER
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 1:338 S DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:VANDENBERG AFB
Mailing Address - State:CA
Mailing Address - Zip Code:93437-6307
Mailing Address - Country:US
Mailing Address - Phone:805-605-4085
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:VANDENBERG AFB
Practice Address - State:CA
Practice Address - Zip Code:93437-6307
Practice Address - Country:US
Practice Address - Phone:805-605-4085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2018-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4200122300000X
WI4200-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN