Healthcare Provider Details

I. General information

NPI: 1396830741
Provider Name (Legal Business Name): KENYON MCGILL FORT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7135 DR. M. L. KING JR., STREET NORTH
ST. PETERSBURG FL
33702
US

IV. Provider business mailing address

7135 DR. M. L. KING JR., STREET NORTH
ST. PETERSBURG FL
33702
US

V. Phone/Fax

Practice location:
  • Phone: 727-525-5455
  • Fax: 727-525-7223
Mailing address:
  • Phone: 727-525-5455
  • Fax: 727-525-7223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDN0012496
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: