MEDICARE: DR. KENNETH S DETTLAFF DMD

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	1223G0001X	General Practice Dentistry	4314T	NV

General Provider Information

NPI Number	:	1467538082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH S DETTLAFF DMD

Provider Business Mailing Address
First Line	:	PO BOX 17179
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92623-7179
Country	:	US
Telephone Number	:	949-567-3176
Fax Number	:	949-567-3185

Provider Business Practice Location Address
First Line	:	1725 E WARM SPRINGS RD STE 2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-0421
Country	:	US
Telephone Number	:	702-270-8790
Fax Number	:	702-270-8928

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

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	07/08/2007

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