Provider Demographics
NPI:1134201361
Name:DR KENNETH R GALLION A PROFESSIONAL DENTAL CORP
Entity type:Organization
Organization Name:DR KENNETH R GALLION A PROFESSIONAL DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:GALLION
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-770-0236
Mailing Address - Street 1:68820 RAMON RD
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234
Mailing Address - Country:US
Mailing Address - Phone:760-770-0236
Mailing Address - Fax:760-770-9758
Practice Address - Street 1:68820 RAMON RD
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234
Practice Address - Country:US
Practice Address - Phone:760-770-0236
Practice Address - Fax:760-770-9758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39405261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental