Provider Demographics
NPI:1417330481
Name:KENNETH J PATTERSON DDS LLC
Entity Type:Organization
Organization Name:KENNETH J PATTERSON DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-288-4882
Mailing Address - Street 1:1608 W YALE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-1569
Mailing Address - Country:US
Mailing Address - Phone:765-288-4882
Mailing Address - Fax:
Practice Address - Street 1:1608 W YALE AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-1569
Practice Address - Country:US
Practice Address - Phone:765-288-4882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011558A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty