Provider Demographics
NPI:1467087320
Name:KENLEY DENTAL
Entity Type:Organization
Organization Name:KENLEY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:KENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-757-6699
Mailing Address - Street 1:5200 N PALMER FISHHOOK RD
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-8317
Mailing Address - Country:US
Mailing Address - Phone:435-757-6699
Mailing Address - Fax:
Practice Address - Street 1:281 N MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7046
Practice Address - Country:US
Practice Address - Phone:435-757-6699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty