Provider Demographics
NPI:1609149533
Name:KENDALL S WOOLRIDGE D,D,S PC
Entity Type:Organization
Organization Name:KENDALL S WOOLRIDGE D,D,S PC
Other - Org Name:GRAND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:SHERRON
Authorized Official - Last Name:WOOLRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-648-8781
Mailing Address - Street 1:310 E GRAND AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3871
Mailing Address - Country:US
Mailing Address - Phone:310-648-8781
Mailing Address - Fax:310-648-8776
Practice Address - Street 1:310 E GRAND AVE STE 106
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3871
Practice Address - Country:US
Practice Address - Phone:310-648-8781
Practice Address - Fax:310-648-8776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA570961223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104006196OtherINDIVIDUAL NPI
CA1609159533OtherTYPE 2 NPI