Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 4300 | KY |
N | 204E00000X | Oral & Maxillofacial Surgeon | 4300 | KY |
NPI | 1487611406 |
---|---|
Provider Name | Mr. Kenneth J Smith |
First Address | Morehead, KY 40351-8852 |
Second Address | Morehead, KY 40351-1443 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
60043007 | (05) | KY |
64043003 | (05) | KY |
T78540 | (02) |