Provider Demographics
NPI:1134284052
Name:MCKENNON, RUDYARD G (DDS)
Entity Type:Individual
Prefix:
First Name:RUDYARD
Middle Name:G
Last Name:MCKENNON
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 1:407 W RIVERSIDE AVE
Mailing Address - Street 2:STE 864
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201
Mailing Address - Country:US
Mailing Address - Phone:509-624-5303
Mailing Address - Fax:509-624-3044
Practice Address - Street 1:407 W RIVERSIDE AVE
Practice Address - Street 2:STE 864
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201
Practice Address - Country:US
Practice Address - Phone:509-624-5303
Practice Address - Fax:509-624-3044
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA99031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5048129Medicaid