Provider Demographics
NPI:1649381062
Name:TATLOCK, KEVIN M (LD)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:TATLOCK
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 SW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-3201
Mailing Address - Country:US
Mailing Address - Phone:541-889-3282
Mailing Address - Fax:541-881-0653
Practice Address - Street 1:473 SW 12TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-3201
Practice Address - Country:US
Practice Address - Phone:541-889-3282
Practice Address - Fax:541-881-0653
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-854277122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR125851Medicaid