Provider Demographics
NPI:1336284413
Name:LEVINE, KENNETH R (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:LEVINE
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 1:8333 W MCNAB RD STE 104
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-3203
Mailing Address - Country:US
Mailing Address - Phone:954-722-1100
Mailing Address - Fax:954-722-1434
Practice Address - Street 1:8333 W MCNAB RD STE 104
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-3203
Practice Address - Country:US
Practice Address - Phone:954-722-1100
Practice Address - Fax:954-722-1434
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN60441223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL591708147OtherTIN