Healthcare Provider Details

I. General information

NPI: 1689664757
Provider Name (Legal Business Name): KENNETH L SCHENCK JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 HIXSON PIKE STE A
HIXSON TN
37343-4466
US

IV. Provider business mailing address

PO BOX 1446
HIXSON TN
37343-5446
US

V. Phone/Fax

Practice location:
  • Phone: 423-875-4812
  • Fax: 423-875-4814
Mailing address:
  • Phone: 423-875-4812
  • Fax: 423-875-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS1883
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: