Provider Demographics
NPI:1831214303
Name:KENNETH L. STASUN D.D.S. A PROFESSIONAL CORPORATEON
Entity type:Organization
Organization Name:KENNETH L. STASUN D.D.S. A PROFESSIONAL CORPORATEON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:STASUN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-726-7523
Mailing Address - Street 1:423 JOHNSTON ST
Mailing Address - Street 2:
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-1717
Mailing Address - Country:US
Mailing Address - Phone:650-726-7523
Mailing Address - Fax:
Practice Address - Street 1:423 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-1717
Practice Address - Country:US
Practice Address - Phone:650-726-7523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA215161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty