Provider Demographics
NPI:1457631608
Name:MCGOWAN, KENNETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:MCGOWAN
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 1:1123 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7434
Mailing Address - Country:US
Mailing Address - Phone:541-773-3422
Mailing Address - Fax:541-779-2250
Practice Address - Street 1:1123 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7434
Practice Address - Country:US
Practice Address - Phone:541-773-3422
Practice Address - Fax:541-779-2250
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD98441223G0001X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5006546600Medicaid