Provider Demographics
NPI:1265942700
Name:KEVIN NIETZER DMD PA
Entity type:Organization
Organization Name:KEVIN NIETZER DMD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIETZER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-997-5902
Mailing Address - Street 1:198 MUTUAL DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-1767
Mailing Address - Country:US
Mailing Address - Phone:864-760-1440
Mailing Address - Fax:864-226-9709
Practice Address - Street 1:198 MUTUAL DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1767
Practice Address - Country:US
Practice Address - Phone:864-760-1440
Practice Address - Fax:864-226-9709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC70031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty