Healthcare Provider Details

I. General information

NPI: 1659370468
Provider Name (Legal Business Name): KEVIN WILLIAM ENSLEY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

3810 SW HALL BLVD
BEAVERTON OR
97005-2048
US

IV. Provider business mailing address

3810 SW HALL BLVD
BEAVERTON OR
97005-2048
US

V. Phone/Fax

Practice location:
  • Phone: 503-643-9509
  • Fax: 503-646-2886
Mailing address:
  • Phone: 503-643-9509
  • Fax: 503-646-2886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6565
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: