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1467538082 NPI number — KENNETH S DETTLAFF DMD

NPI Number: 1467538082
Health Care Provider/Practitioner: KENNETH S DETTLAFF DMD

Information about “1467538082” NPI (KENNETH S DETTLAFF DMD) exists in 1467538082 in HTML format HTML  |  1467538082 in plain Text format TXT  |  1467538082 in PDF (Portable Document Format) PDF  |  1467538082 in an XML format XML  formats.

NPI Number : 1467538082 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1467538082",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "DETTLAFF",
    "FirstName": "KENNETH",
    "MiddleName": "S",
    "NamePrefix": "DR.",
    "NameSuffix": null,
    "Credential": "DMD",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "PO BOX 17179",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "IRVINE",
    "MailingAddressStateName": "CA",
    "MailingAddressPostalCode": "92623-7179",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "949-567-3176",
    "MailingAddressFaxNumber": "949-567-3185",
    "FirstLinePracticeLocationAddress": "1725 E WARM SPRINGS RD STE 2",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "LAS VEGAS",
    "PracticeLocationAddressStateName": "NV",
    "PracticeLocationAddressPostalCode": "89119-0421",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "702-270-8790",
    "PracticeLocationAddressFaxNumber": "702-270-8928",
    "EnumerationDate": "10/27/2006",
    "LastUpdateDate": "07/08/2007",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "1223G0001X",
        "TaxonomyName": "General Practice Dentistry",
        "LicenseNumber": "4314T",
        "LicenseNumberStateCode": "NV",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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