Provider Demographics
NPI:1396832028
Name:HARTENIAN, KENNETH MARTIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARTIN
Last Name:HARTENIAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 E WALDO BLVD
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220
Mailing Address - Country:US
Mailing Address - Phone:920-684-3353
Mailing Address - Fax:920-684-8786
Practice Address - Street 1:33 E WALDO BLVD
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220
Practice Address - Country:US
Practice Address - Phone:920-684-3353
Practice Address - Fax:920-684-8786
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50013231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI70032900Medicaid
WI70032900Medicaid
WI78305Medicare ID - Type Unspecified