Provider Demographics
NPI:1154558328
Name:WEITZEL, KEVIN TIMOTHY (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TIMOTHY
Last Name:WEITZEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 FISHINGER BLVD
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-7504
Mailing Address - Country:US
Mailing Address - Phone:614-876-4277
Mailing Address - Fax:614-777-0424
Practice Address - Street 1:3535 FISHINGER BLVD
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-7504
Practice Address - Country:US
Practice Address - Phone:614-876-4277
Practice Address - Fax:614-777-0424
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-022995122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3104992Medicare PIN