Basic Information
| Provider Information | |||||||||
| NPI: | 1609437326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCHWIETERMAN | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 424 WARDS CORNER RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451406966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137074041 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4327 AICHOLTZ RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452451504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137532821 | ||||||||
| FaxNumber: | 5135280593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2019 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 30025882 | OH | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 0356938 | 05 | OH | MEDICAID |