Provider Demographics
NPI:1508949249
Name:PURVIS, KENNETH GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GARY
Last Name:PURVIS
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 1:1010 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-1810
Mailing Address - Country:US
Mailing Address - Phone:724-530-3541
Mailing Address - Fax:724-537-9771
Practice Address - Street 1:1010 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-1810
Practice Address - Country:US
Practice Address - Phone:724-530-3541
Practice Address - Fax:724-537-9771
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018076L1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA114018Medicare UPIN