=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265988620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENWORTHY DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2016
-----------------------------------------------------
Last Update Date | 08/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 SUNRISE AVE STE 140
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-4567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-780-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 730 SUNRISE AVE STE 140
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-4567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-780-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNEE
-----------------------------------------------------
Name | RUTH KENWORTHY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-780-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------