Healthcare Provider Details

I. General information

NPI: 1609459346
Provider Name (Legal Business Name): KENNETH HANCOCK DDS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 4TH AVE E STE 100
OLYMPIA WA
98506-4484
US

IV. Provider business mailing address

1401 4TH AVE E STE 100
OLYMPIA WA
98506-4484
US

V. Phone/Fax

Practice location:
  • Phone: 360-753-7388
  • Fax: 360-753-3553
Mailing address:
  • Phone: 360-753-7388
  • Fax: 360-753-3553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KENNETH L HANCOCK
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 360-753-7388