Provider Demographics
NPI:1558927020
Name:KNOWLES, KENDON KELLY (DMD)
Entity Type:Individual
Prefix:
First Name:KENDON
Middle Name:KELLY
Last Name:KNOWLES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-988-0996
Mailing Address - Fax:
Practice Address - Street 1:5240 N TOWNE CENTRE DR STE 201
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9075
Practice Address - Country:US
Practice Address - Phone:417-581-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7152122300000X
MO20210126101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist