Provider Demographics
NPI:1295749711
Name:KNEISLEY, JACK R (DDS)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:R
Last Name:KNEISLEY
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 1:221 E HOME RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503
Mailing Address - Country:US
Mailing Address - Phone:937-399-4470
Mailing Address - Fax:937-399-3338
Practice Address - Street 1:221 E HOME RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503
Practice Address - Country:US
Practice Address - Phone:937-399-4470
Practice Address - Fax:937-399-3338
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH145781223G0001X
NH12821223G0001X
MA124261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice