Provider Demographics
NPI:1659370468
Name:ENSLEY, KEVIN WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:ENSLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 SW HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2048
Mailing Address - Country:US
Mailing Address - Phone:503-643-9509
Mailing Address - Fax:503-646-2886
Practice Address - Street 1:3810 SW HALL BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2048
Practice Address - Country:US
Practice Address - Phone:503-643-9509
Practice Address - Fax:503-646-2886
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
OR65651223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics