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General NPI Number Information
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NPI Number | 1053713347
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Entity Type | Individual
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Provider Name | KENNETH BARRY
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Gender | Male
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Dates
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Enumeration Date | 09/18/2014
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Last Update Date | 09/18/2014
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Provider Practice Location Address
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Address Line | 1252 AIRPORT PARK BLVD SUITE D1
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City | UKIAH
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State | CA
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Zip | 95482-5979
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Country | US
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Telephone | 707-462-8719
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Fax |
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Provider Business Mailing Address
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Address Line | 1252 AIRPORT PARK BLVD SUITE D1
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City | UKIAH
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State | CA
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Zip | 95482-5979
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 25477
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License Number State | CA
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