Healthcare Provider Details

I. General information

NPI: 1689084550
Provider Name (Legal Business Name): KENLEY D MICHAUD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 W NORTHERN LIGHTS BLVD STE 623
ANCHORAGE AK
99503-2337
US

IV. Provider business mailing address

1231 W NORTHERN LIGHTS BLVD STE 623
ANCHORAGE AK
99503-2337
US

V. Phone/Fax

Practice location:
  • Phone: 415-375-0607
  • Fax:
Mailing address:
  • Phone: 415-375-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number1547
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: