=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043466089
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH B. BOYD SR. DDS, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2008
-----------------------------------------------------
Last Update Date | 08/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 838 OLD GEORGE WASHINGTON HWY N C
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23323-2209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-558-9008
-----------------------------------------------------
Fax | 757-558-9042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 838 OLD GEORGE WASHINGTON HWY N C
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23323-2209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-558-9008
-----------------------------------------------------
Fax | 757-558-9042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KENNETH BERNARD BOYD SR.
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 757-558-9008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401007988
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------