Provider Demographics
NPI:1003052770
Name:SALO, KENNETH DONALD (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DONALD
Last Name:SALO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11816 MISSISSIPPI DR N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-2513
Mailing Address - Country:US
Mailing Address - Phone:763-421-2732
Mailing Address - Fax:
Practice Address - Street 1:11816 MISSISSIPPI DR N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-2513
Practice Address - Country:US
Practice Address - Phone:763-421-2732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN68001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice