Provider Demographics
NPI:1558475079
Name:PEDERSEN, KEN C (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEN
Middle Name:C
Last Name:PEDERSEN
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 1:111 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-2916
Mailing Address - Country:US
Mailing Address - Phone:308-234-2828
Mailing Address - Fax:308-234-1099
Practice Address - Street 1:111 W 31ST ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-2916
Practice Address - Country:US
Practice Address - Phone:308-234-2828
Practice Address - Fax:308-234-1099
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE54591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice