Provider Demographics
NPI:1578747655
Name:EIFERT, KENNETH GRAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GRAY
Last Name:EIFERT
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 1:1 MAIN ST
Mailing Address - Street 2:SAN QUENTIN SP
Mailing Address - City:SAN QUENTIN
Mailing Address - State:CA
Mailing Address - Zip Code:94964
Mailing Address - Country:US
Mailing Address - Phone:415-454-1460
Mailing Address - Fax:415-455-5165
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:SAN QUENTIN SP
Practice Address - City:SAN QUENTIN
Practice Address - State:CA
Practice Address - Zip Code:94964
Practice Address - Country:US
Practice Address - Phone:415-454-1460
Practice Address - Fax:415-455-5165
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA358771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice