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NPI Code Detail

MEDICARE: KENNETH LEGAULT

MEDICARE: KENNETH LEGAULT
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
11223G0001XGeneral Practice Dentistry12008504AIN

General Provider Information

NPI Number : 1841361011
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNETH LEGAULT
Provider Business Mailing Address
First Line : 415 N GRAND AVE
Second Line :
City : PUEBLO
State : CO
Zip : 81003-3111
Country : US
Telephone Number : 719-583-1800
Fax Number :
Provider Business Practice Location Address
First Line : 5430 E WASHINGTON ST
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46219-6446
Country : US
Telephone Number : 317-322-1840
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/10/2006
Last Update Date : 07/09/2007

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Directions to “ KENNETH LEGAULT ” Practice Location

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