Provider Demographics
NPI:1699845586
Name:MINIMAN, KENNETH L (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:MINIMAN
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 1:1022 E BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5122
Mailing Address - Country:US
Mailing Address - Phone:610-565-7850
Mailing Address - Fax:610-565-8626
Practice Address - Street 1:1022 EAST BALTIMORE PK
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5122
Practice Address - Country:US
Practice Address - Phone:610-565-7850
Practice Address - Fax:610-565-8626
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019654L1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry