Provider Demographics
NPI:1457543613
Name:GLASS, KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:GLASS
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 1:680 GAIL GARDNER WAY
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305
Mailing Address - Country:US
Mailing Address - Phone:928-445-9233
Mailing Address - Fax:928-445-1758
Practice Address - Street 1:680 GAIL GARDNER WAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305
Practice Address - Country:US
Practice Address - Phone:928-445-9233
Practice Address - Fax:928-445-1758
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ66821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice