Provider Demographics
NPI:1336395128
Name:ROSS, KENNETH MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:ROSS
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 1:1822 W BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1348
Mailing Address - Country:US
Mailing Address - Phone:818-848-5619
Mailing Address - Fax:
Practice Address - Street 1:1822 W BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1348
Practice Address - Country:US
Practice Address - Phone:818-848-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25023122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist