=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083435960
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH L JONES II DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2024
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 179 ELMIRA RD STE H
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95687-4732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-446-6236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 ALLISON DR APT 246
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95687-4992
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-515-9417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 110575
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------