Provider Demographics
NPI:1023361896
Name:VANDERVOORT, KENNETH LUCKIE JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LUCKIE
Last Name:VANDERVOORT
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 GLADSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35213-1415
Mailing Address - Country:US
Mailing Address - Phone:256-239-3890
Mailing Address - Fax:
Practice Address - Street 1:1117 GLADSTONE AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35213-1415
Practice Address - Country:US
Practice Address - Phone:256-239-3890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist