Provider Demographics
NPI:1023109006
Name:SOFRANKO, KENNETH MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:SOFRANKO
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 1:928 BRODHEAD RD
Mailing Address - Street 2:
Mailing Address - City:MOON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:15108-2375
Mailing Address - Country:US
Mailing Address - Phone:412-264-2405
Mailing Address - Fax:412-264-3810
Practice Address - Street 1:928 BRODHEAD RD
Practice Address - Street 2:
Practice Address - City:MOON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:15108-2375
Practice Address - Country:US
Practice Address - Phone:412-264-2405
Practice Address - Fax:412-264-3810
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024919L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011753540001Medicaid