Basic Information
| Provider Information | |||||||||
| NPI: | 1841429339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GRANT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W CENTER STREET PROMENADE STE 400 | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928053960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144494841 | ||||||||
| FaxNumber: | 7144494956 | ||||||||
| Practice Location | |||||||||
| Address1: | 3307 RENNER DR | ||||||||
| Address2: | |||||||||
| City: | FORTUNA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955403119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077259832 | ||||||||
| FaxNumber: | 7077257247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2009 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A151367 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 4301095163 | MI | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036139694 | 01 | IL | LICENSE | OTHER |