Provider Demographics
NPI:1811035306
Name:MOORE, KENNETH EARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EARL
Last Name:MOORE
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 1:729 SUNRISE AVE
Mailing Address - Street 2:STE #400
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4526
Mailing Address - Country:US
Mailing Address - Phone:916-780-2022
Mailing Address - Fax:916-784-7491
Practice Address - Street 1:729 SUNRISE AVE
Practice Address - Street 2:STE #400
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4526
Practice Address - Country:US
Practice Address - Phone:916-780-2022
Practice Address - Fax:916-784-7491
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA30946122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist