Provider Demographics
NPI:1124009816
Name:BUILDER, KENNETH MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARK
Last Name:BUILDER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:BUILDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-0080
Mailing Address - Country:US
Mailing Address - Phone:541-265-4221
Mailing Address - Fax:541-574-6552
Practice Address - Street 1:123 SE DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4426
Practice Address - Country:US
Practice Address - Phone:541-265-4221
Practice Address - Fax:541-574-6552
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7773122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR131115Medicare ID - Type Unspecified