MEDICARE: DR. KENDALL SHERRON WOOLRIDGE D.D.S.

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
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	053717	NY
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	57096	CA

General Provider Information

NPI Number	:	1104006196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENDALL SHERRON WOOLRIDGE D.D.S.

Provider Business Mailing Address
First Line	:	310 E GRAND AVE STE 106
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-3871
Country	:	US
Telephone Number	:	310-648-8781
Fax Number	:	661-648-8776

Provider Business Practice Location Address
First Line	:	310 E GRAND AVE STE 106
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-3871
Country	:	US
Telephone Number	:	310-648-8781
Fax Number	:	661-648-8776

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2007
Last Update Date	:	07/16/2015

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