Provider Demographics
NPI:1154662690
Name:BLOODWORTH, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BLOODWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 LANTANA CIR
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-1109
Mailing Address - Country:US
Mailing Address - Phone:210-393-1704
Mailing Address - Fax:
Practice Address - Street 1:2001 WINDY TER
Practice Address - Street 2:STE F
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-4289
Practice Address - Country:US
Practice Address - Phone:210-393-1704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11369122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist