Provider Demographics
NPI:1841420585
Name:KNIERIM, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KNIERIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 REGENCY CT
Mailing Address - Street 2:101
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-3091
Mailing Address - Country:US
Mailing Address - Phone:419-473-2728
Mailing Address - Fax:
Practice Address - Street 1:1000 REGENCY CT
Practice Address - Street 2:101
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3091
Practice Address - Country:US
Practice Address - Phone:419-473-2728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist