Provider Demographics
NPI:1720206899
Name:TOM, WILLIAM KENNETH (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:KENNETH
Last Name:TOM
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 S DORA ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5466
Mailing Address - Country:US
Mailing Address - Phone:707-462-6983
Mailing Address - Fax:
Practice Address - Street 1:620 S DORA ST
Practice Address - Street 2:SUITE 205
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5466
Practice Address - Country:US
Practice Address - Phone:707-462-6983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA377471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery