Healthcare Provider Details

I. General information

NPI: 1467538082
Provider Name (Legal Business Name): KENNETH S DETTLAFF DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 E WARM SPRINGS RD STE 2
LAS VEGAS NV
89119-0421
US

IV. Provider business mailing address

PO BOX 17179
IRVINE CA
92623-7179
US

V. Phone/Fax

Practice location:
  • Phone: 702-270-8790
  • Fax: 702-270-8928
Mailing address:
  • Phone: 949-567-3176
  • Fax: 949-567-3185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4314T
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: