=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801253505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNETH RICKS DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2016
-----------------------------------------------------
Last Update Date | 01/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5601 AUBURN ST UNIT B
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93306-2977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-432-7773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5601 AUBURN ST UNIT B
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93306-2977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-432-7773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KENNETH GORDON RICKS JR.
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 661-432-7773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------