Provider Demographics
NPI:1750377966
Name:WATERBROOK, KENTON LEE (DO)
Entity type:Individual
Prefix:
First Name:KENTON
Middle Name:LEE
Last Name:WATERBROOK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3370 E JOLLY RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-8552
Mailing Address - Country:US
Mailing Address - Phone:517-487-3717
Mailing Address - Fax:517-487-3472
Practice Address - Street 1:3370 E JOLLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8552
Practice Address - Country:US
Practice Address - Phone:517-487-3717
Practice Address - Fax:517-487-3472
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKW008742207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1912972Medicaid
F22786Medicare UPIN
MI1912972Medicaid