Provider Demographics
NPI:1265587133
Name:KOLZ, KENNETH EUGENE (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EUGENE
Last Name:KOLZ
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 1:791 CAMDEN VISTA CT
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-5066
Mailing Address - Country:US
Mailing Address - Phone:805-526-5435
Mailing Address - Fax:
Practice Address - Street 1:1987 ROYAL AVE STE 2
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-4655
Practice Address - Country:US
Practice Address - Phone:805-526-8637
Practice Address - Fax:805-578-2307
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22239122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist