Provider Demographics
NPI:1720678618
Name:DEPOLO, KENNETH RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RICHARD
Last Name:DEPOLO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9880 NEWKIRK DR
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3139
Mailing Address - Country:US
Mailing Address - Phone:440-454-9665
Mailing Address - Fax:
Practice Address - Street 1:9880 NEWKIRK DR
Practice Address - Street 2:
Practice Address - City:PARMA HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3139
Practice Address - Country:US
Practice Address - Phone:440-454-9665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.026359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist