Healthcare Provider Details

I. General information

NPI: 1366450413
Provider Name (Legal Business Name): KENNETH ALLEN STORUM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 CAMINO DEL RIO NORTH #140
SAN DIEGO CA
92108
US

IV. Provider business mailing address

2655 CAMINO DEL RIO NORTH #140
SAN DIEGO CA
92108
US

V. Phone/Fax

Practice location:
  • Phone: 619-282-7088
  • Fax: 619-282-6290
Mailing address:
  • Phone: 619-282-7088
  • Fax: 619-282-6290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number030774
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: