Provider Demographics
NPI:1447742358
Name:STUART, KENNETH JOSEPH (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOSEPH
Last Name:STUART
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 1:2344 N MERRIT CRK LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4950
Mailing Address - Country:US
Mailing Address - Phone:208-512-4130
Mailing Address - Fax:
Practice Address - Street 1:2344 N MERRIT CRK LOOP
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4950
Practice Address - Country:US
Practice Address - Phone:208-512-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYS15-692-1351223G0001X
IDD-55541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty