Provider Demographics
NPI:1245481175
Name:JOSEPH H. CIESLAK DDS, PLLC
Entity type:Organization
Organization Name:JOSEPH H. CIESLAK DDS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:CIESLAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:502-939-2500
Mailing Address - Street 1:6501 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3907
Mailing Address - Country:US
Mailing Address - Phone:502-937-2500
Mailing Address - Fax:
Practice Address - Street 1:6501 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-3907
Practice Address - Country:US
Practice Address - Phone:502-937-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74070386Medicaid
KYU63575Medicare UPIN