Provider Demographics
NPI:1669554119
Name:BALDWIN, KENNETH J (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:BALDWIN
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 1:4046 HIGHLAND DR
Mailing Address - Street 2:SUITE #112
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1673
Mailing Address - Country:US
Mailing Address - Phone:801-273-5600
Mailing Address - Fax:801-273-5678
Practice Address - Street 1:4046 HIGHLAND DR
Practice Address - Street 2:SUITE #112
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1673
Practice Address - Country:US
Practice Address - Phone:801-273-5600
Practice Address - Fax:801-273-5678
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144670-99241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU18401Medicare UPIN