Provider Demographics
NPI:1881721298
Name:COLERICK, KENNETH CHARLES (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:CHARLES
Last Name:COLERICK
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:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91708
Mailing Address - Country:US
Mailing Address - Phone:909-627-4177
Mailing Address - Fax:
Practice Address - Street 1:847 E PHILADELPHIA ST
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766
Practice Address - Country:US
Practice Address - Phone:909-627-4177
Practice Address - Fax:909-628-8018
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist