Provider Demographics
NPI:1386750677
Name:CHMIELEWSKI, KATHLEEN HURST (DDS)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:HURST
Last Name:CHMIELEWSKI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:HURST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:7709 BROCKWAY RD
Mailing Address - Street 2:P.O. BOX 153
Mailing Address - City:BROCKWAY
Mailing Address - State:MI
Mailing Address - Zip Code:48097-3411
Mailing Address - Country:US
Mailing Address - Phone:810-387-3055
Mailing Address - Fax:810-387-3121
Practice Address - Street 1:7709 BROCKWAY RD
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:MI
Practice Address - Zip Code:48097-3411
Practice Address - Country:US
Practice Address - Phone:810-387-3055
Practice Address - Fax:810-387-3121
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI150381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2696166Medicaid