Kenneth DO, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DENT.DE.61563404 Issued in WA

Practice address

109 S 65TH Ave Ste 104
Ridgefield, WA 98642-3708

Phone

(360) 887-2333

NPI assigned

May 14, 2024

Last updated

May 14, 2024By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Ctr Dental Northwest

  dba Pacific Crest Smiles Dental

  • General Practice Dentistry
  • Roseburg, OR
  • NPI 1467253161
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1715644800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1715644800000",
    "number": "1467201400",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8423 BRIGHTON LAKE LN",
            "city": "HOUSTON",
            "state": "TX",
            "postal_code": "770954761"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "109 S 65TH AVE STE 104",
            "city": "RIDGEFIELD",
            "state": "WA",
            "postal_code": "986423708",
            "telephone_number": "360-887-2333"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DO",
        "first_name": "KENNETH",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2024-05-14",
        "last_updated": "2024-05-14",
        "certification_date": "2024-05-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "WA",
            "license": "DENT.DE.61563404",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Zoralei Dayley, DPT
• Anyssa De Vera
• Jarred Gregory Degree
• Dental Professionals of Washington, Quirt, Mongrain, Gibree, PC
• Daniel A Derevyanchuk, CRNA
• Dr. Drew Morgan, DC (Hands With Heart Chiropractic)
• Michelle Marie Dragoo, L.M.P.
• Josephine Elizabeth Drew, M.D
• Eid, Jaber, Jassar PLLC
• Mikha'El Eliyahu

• General Practice Dentistry in Ridgefield, WA
• Providers in Ridgefield, WA by specialty
• General Practice Dentistry in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 14, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.