=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104006196
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENDALL SHERRON WOOLRIDGE D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2007
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 E GRAND AVE STE 106
-----------------------------------------------------
City | EL SEGUNDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90245-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-648-8781
-----------------------------------------------------
Fax | 661-648-8776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 E GRAND AVE STE 106
-----------------------------------------------------
City | EL SEGUNDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90245-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-648-8781
-----------------------------------------------------
Fax | 661-648-8776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 053717
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 57096
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------