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NPI Code Detail

MEDICARE: DR. KENNETH BYRON WILTBANK D.M.D.

MEDICARE: DR. KENNETH BYRON WILTBANK D.M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentistD7468OR

General Provider Information

NPI Number : 1003015496
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KENNETH BYRON WILTBANK D.M.D.
Provider Business Mailing Address
First Line : 320 A AVENUE
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97034
Country : US
Telephone Number : 503-636-3383
Fax Number :
Provider Business Practice Location Address
First Line : 320 A AVE
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97034-3056
Country : US
Telephone Number : 503-636-3383
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/16/2007
Last Update Date : 07/16/2007

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