Provider Demographics
NPI:1063631679
Name:SANGIACOMO, KENNETH S (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
Last Name:SANGIACOMO
Suffix:
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 1:27 GRASSY PLAIN ST
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-1703
Mailing Address - Country:US
Mailing Address - Phone:203-743-5600
Mailing Address - Fax:203-743-2955
Practice Address - Street 1:27 GRASSY PLAIN ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-1703
Practice Address - Country:US
Practice Address - Phone:203-743-5600
Practice Address - Fax:203-743-2955
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT78281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice