Provider Demographics
NPI:1003818972
Name:LENTZ, KENNETH JOHN JR (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:LENTZ
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 665
Mailing Address - Street 2:
Mailing Address - City:SPRUCE PINE
Mailing Address - State:NC
Mailing Address - Zip Code:28777-0665
Mailing Address - Country:US
Mailing Address - Phone:828-765-7788
Mailing Address - Fax:828-765-6247
Practice Address - Street 1:193 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:SPRUCE PINE
Practice Address - State:NC
Practice Address - Zip Code:28777-2738
Practice Address - Country:US
Practice Address - Phone:828-765-4349
Practice Address - Fax:828-765-6247
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0983152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909545Medicaid
NC22-09157OtherUS HEALTH CARE
T64634Medicare UPIN
NC8909545Medicaid