Healthcare Provider Details

I. General information

NPI: 1467087320
Provider Name (Legal Business Name): KENLEY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 N MAIN ST STE 201
WASILLA AK
99654-7046
US

IV. Provider business mailing address

5200 N PALMER FISHHOOK RD
PALMER AK
99645-8317
US

V. Phone/Fax

Practice location:
  • Phone: 435-757-6699
  • Fax:
Mailing address:
  • Phone: 435-757-6699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CALVIN MATTHEW KENLEY
Title or Position: DOCTOR
Credential: DMD
Phone: 435-757-6699