Provider Demographics
NPI:1982227203
Name:DORNER, KENNETH A (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:DORNER
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 1:2415 MULLINS AVE UNIT 5
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-4264
Mailing Address - Country:US
Mailing Address - Phone:719-992-2101
Mailing Address - Fax:
Practice Address - Street 1:2415 MULLINS AVE UNIT 5
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-4264
Practice Address - Country:US
Practice Address - Phone:719-992-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00204366122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist