MEDICARE: DR. KENNETH CHARLES BOYLE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DSO26322L	PA

General Provider Information

NPI Number	:	1487694451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH CHARLES BOYLE DMD

Provider Business Mailing Address
First Line	:	111 E BROAD ST
Second Line	:
City	:	WEST HAZLETON
State	:	PA
Zip	:	18202-3811
Country	:	US
Telephone Number	:	570-459-2263
Fax Number	:	570-459-5922

Provider Business Practice Location Address
First Line	:	111 E BROAD ST
Second Line	:
City	:	WEST HAZLETON
State	:	PA
Zip	:	18202-3811
Country	:	US
Telephone Number	:	570-459-2263
Fax Number	:	570-459-5922

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	07/08/2007

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