Provider Demographics
NPI:1093921868
Name:DEACON, KENNETH JEROME (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JEROME
Last Name:DEACON
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 1:3525 RESOURCE DR
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4733
Mailing Address - Country:US
Mailing Address - Phone:410-887-0613
Mailing Address - Fax:410-887-0713
Practice Address - Street 1:9100 FRANKLIN SQUARE DR
Practice Address - Street 2:EASTERN FAMILY RESOURCE CENTER DENTAL CLINIC
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3903
Practice Address - Country:US
Practice Address - Phone:410-887-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2015-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD81701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice