Provider Demographics
NPI:1427417856
Name:WADSWORTH, KENTON (DACM, LAC)
Entity Type:Individual
Prefix:DR
First Name:KENTON
Middle Name:
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 W WACKERLY ST STE E
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6994
Mailing Address - Country:US
Mailing Address - Phone:571-417-8463
Mailing Address - Fax:
Practice Address - Street 1:2621 W WACKERLY ST STE E
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6994
Practice Address - Country:US
Practice Address - Phone:989-496-7472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-13
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000803171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist