Provider Demographics
NPI:1871674069
Name:PERINO, KENNETH EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EUGENE
Last Name:PERINO
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 1:2532 PATTERSON ROAD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1098
Mailing Address - Country:US
Mailing Address - Phone:970-241-2820
Mailing Address - Fax:970-248-9553
Practice Address - Street 1:2532 PATTERSON ROAD
Practice Address - Street 2:SUITE 10
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1098
Practice Address - Country:US
Practice Address - Phone:970-241-2820
Practice Address - Fax:970-248-9553
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHD1047421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02047421Medicaid
85765Medicare ID - Type Unspecified
T60810Medicare UPIN