Provider Demographics
NPI:1740458389
Name:KIENLE, MARK P (MD, DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:KIENLE
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 YORK RD
Mailing Address - Street 2:
Mailing Address - City:WARMINSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18974-4521
Mailing Address - Country:US
Mailing Address - Phone:215-672-6560
Mailing Address - Fax:215-672-7343
Practice Address - Street 1:158 YORK RD
Practice Address - Street 2:
Practice Address - City:WARMINSTER
Practice Address - State:PA
Practice Address - Zip Code:18974-4521
Practice Address - Country:US
Practice Address - Phone:215-672-6560
Practice Address - Fax:215-672-7343
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-18
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.022637122300000X
PAMD449368204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA310363EL3Medicare PIN