Active NPI
Kenneth DO, DDS
- General Practice Dentistry
- Ridgefield, WA
National Provider Identifier
1467201400
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- DENT.DE.61563404
- Practice address
- 109 S 65TH Ave Ste 104
Ridgefield, WA 98642-3708 - Phone
- (360) 887-2333
- NPI assigned
- May 14, 2024
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | DENT.DE.61563404 | WA | Primary |
Addresses
Primary practice location
109 S 65TH Ave Ste 104
Ridgefield, WA 98642-3708
Mailing address
8423 Brighton Lake LN
Houston, TX 77095-4761
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DENT.DE.61563404 | WA | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Ctr Dental Northwest | General Practice | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
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": []
}Other providers in Ridgefield, WA
Sources for this page
- 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.