Healthcare Provider Details

I. General information

NPI: 1841343308
Provider Name (Legal Business Name): KENNETH D. OWEN, DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 N WENDOVER RD
CHARLOTTE NC
28211-1064
US

IV. Provider business mailing address

497 N WENDOVER RD
CHARLOTTE NC
28211-1064
US

V. Phone/Fax

Practice location:
  • Phone: 704-366-8006
  • Fax: 704-364-9390
Mailing address:
  • Phone: 704-366-8006
  • Fax: 704-364-9390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2908
License Number StateNC

VIII. Authorized Official

Name: DR. KENNETH DALE OWEN SR.
Title or Position: ORTHODONTIST
Credential: D.D.S., M.SC.O.
Phone: 704-366-8006