Provider Demographics
NPI:1639207079
Name:TITTLE, KENNETH W (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:TITTLE
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 1:401 GREGORY LN STE 118
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2851
Mailing Address - Country:US
Mailing Address - Phone:925-676-3388
Mailing Address - Fax:925-798-3863
Practice Address - Street 1:401 GREGORY LN STE 118
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2851
Practice Address - Country:US
Practice Address - Phone:925-676-3388
Practice Address - Fax:925-798-3863
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA377451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics