Healthcare Provider Details

I. General information

NPI: 1043954837
Provider Name (Legal Business Name): KENTON CRAIG COVINGTON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 S FERDON BLVD
CRESTVIEW FL
32536-8508
US

IV. Provider business mailing address

2156 SIENA TER
HOLLYWOOD FL
33021-3800
US

V. Phone/Fax

Practice location:
  • Phone: 850-477-1089
  • Fax:
Mailing address:
  • Phone: 520-488-1695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number24724
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: