Provider Demographics
NPI:1255338638
Name:MIZE, KENNETH G (DMDPC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
Last Name:MIZE
Suffix:
Gender:M
Credentials:DMDPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W MAIN ST
Mailing Address - Street 2:P.O. BOX 100
Mailing Address - City:SHERIDAN
Mailing Address - State:OR
Mailing Address - Zip Code:97378-1117
Mailing Address - Country:US
Mailing Address - Phone:503-843-4433
Mailing Address - Fax:503-843-4434
Practice Address - Street 1:411 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:OR
Practice Address - Zip Code:97378-1117
Practice Address - Country:US
Practice Address - Phone:503-843-4433
Practice Address - Fax:503-843-4434
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD58111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice