Healthcare Provider Details

I. General information

NPI: 1417935784
Provider Name (Legal Business Name): KENNETH REID DIBBLE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 NORTHWEST HWY
GARLAND TX
75041-5231
US

IV. Provider business mailing address

1509 NORTHWEST HWY
GARLAND TX
75041-5231
US

V. Phone/Fax

Practice location:
  • Phone: 972-840-6100
  • Fax:
Mailing address:
  • Phone: 972-840-6100
  • Fax: 801-572-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number38325
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5136779-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: