Provider Demographics
NPI:1053713347
Name:BARRY, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BARRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 AIRPORT PARK BLVD
Mailing Address - Street 2:SUITE D1
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5979
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1252 AIRPORT PARK BLVD
Practice Address - Street 2:SUITE D1
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5979
Practice Address - Country:US
Practice Address - Phone:707-462-8719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA254771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice