Provider Demographics
NPI:1619329307
Name:HORTMAN, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:HORTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 900
Mailing Address - Street 2:
Mailing Address - City:ROBERTA
Mailing Address - State:GA
Mailing Address - Zip Code:31078-0900
Mailing Address - Country:US
Mailing Address - Phone:478-836-2994
Mailing Address - Fax:
Practice Address - Street 1:143 E CRUSSELLE ST
Practice Address - Street 2:
Practice Address - City:ROBERTA
Practice Address - State:GA
Practice Address - Zip Code:31078-4866
Practice Address - Country:US
Practice Address - Phone:478-836-2994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist