Provider Demographics
NPI:1912949934
Name:ROLL, KENNETH SHERMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:SHERMAN
Last Name:ROLL
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 1:130 N FRONT ST
Mailing Address - Street 2:SUITE #8
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3741
Mailing Address - Country:US
Mailing Address - Phone:845-338-8812
Mailing Address - Fax:845-338-9086
Practice Address - Street 1:130 N FRONT ST
Practice Address - Street 2:SUITE #8
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3741
Practice Address - Country:US
Practice Address - Phone:845-338-8812
Practice Address - Fax:845-338-9086
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0330371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00636728Medicaid
NY00636728Medicaid