Provider Demographics
NPI:1497891469
Name:HILL, KENNETH WILLARD (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WILLARD
Last Name:HILL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 SUMMAR AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301
Mailing Address - Country:US
Mailing Address - Phone:731-421-6764
Mailing Address - Fax:731-421-5148
Practice Address - Street 1:295 SUMMAR AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301
Practice Address - Country:US
Practice Address - Phone:731-421-6764
Practice Address - Fax:731-421-5148
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS2635122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225766Medicaid