Healthcare Provider Details

I. General information

NPI: 1639187883
Provider Name (Legal Business Name): KENNETH E SYKES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BRIDGEWOOD DR SUITE 126
FORT WORTH TX
76112-0826
US

IV. Provider business mailing address

1100 BRIDGEWOOD DR SUITE 126
FORT WORTH TX
76112-0826
US

V. Phone/Fax

Practice location:
  • Phone: 817-451-4911
  • Fax: 817-451-6443
Mailing address:
  • Phone: 817-451-4911
  • Fax: 817-451-6443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD12704
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: