Provider Demographics
NPI:1043326390
Name:PARKS, KENNETH W (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:PARKS
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 1:636 WEST MCNEESE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605
Mailing Address - Country:US
Mailing Address - Phone:337-477-6124
Mailing Address - Fax:337-477-6885
Practice Address - Street 1:636 WEST MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605
Practice Address - Country:US
Practice Address - Phone:337-477-6124
Practice Address - Fax:337-477-6885
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA38731223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1838730Medicaid
G1204OtherBLUE CROSS OF LA
807933OtherUNITED CONCORDIA
LA1838730Medicaid