Provider Demographics
NPI:1508873373
Name:WILSON, KENNETH ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:WILSON
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 1:13764 E QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-1129
Mailing Address - Country:US
Mailing Address - Phone:303-690-0877
Mailing Address - Fax:303-690-1250
Practice Address - Street 1:13764 E QUINCY AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1129
Practice Address - Country:US
Practice Address - Phone:303-690-0877
Practice Address - Fax:303-690-1250
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO105011122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist