Basic Information
| Provider Information | |||||||||
| NPI: | 1750545588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34703 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067643335 | ||||||||
| FaxNumber: | 2067640489 | ||||||||
| Practice Location | |||||||||
| Address1: | 1412 NE 88TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986659620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605744074 | ||||||||
| FaxNumber: | 3605749237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DE00009608 | WA | Y | Dental Providers | Dentist | General Practice |
No ID Information.