Provider Demographics
NPI:1619364353
Name:ANDRYC, KENTON CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:KENTON
Middle Name:CHRISTOPHER
Last Name:ANDRYC
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 1:7686 W RIDGE RD
Mailing Address - Street 2:FAIRVIEW
Mailing Address - City:FAIRVIEW
Mailing Address - State:PA
Mailing Address - Zip Code:16415-1074
Mailing Address - Country:US
Mailing Address - Phone:814-474-1527
Mailing Address - Fax:814-474-5022
Practice Address - Street 1:7686 W RIDGE RD
Practice Address - Street 2:FAIRVIEW
Practice Address - City:FAIRVIEW
Practice Address - State:PA
Practice Address - Zip Code:16415-1074
Practice Address - Country:US
Practice Address - Phone:814-474-1527
Practice Address - Fax:814-474-5022
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040398122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist