Healthcare Provider Details

I. General information

NPI: 1265453187
Provider Name (Legal Business Name): KENNETH WILLIAM LAUDENBACH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 LOCUST ST SUITE 600
PHILADELPHIA PA
19102-4403
US

IV. Provider business mailing address

1520 LOCUST ST SUITE 600
PHILADELPHIA PA
19102-4403
US

V. Phone/Fax

Practice location:
  • Phone: 215-985-4337
  • Fax:
Mailing address:
  • Phone: 215-985-4337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS17161L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: