MEDICARE: KENDALL S WOOLRIDGE D,D,S PC

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	57096	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1104006196	OTHER	CA	INDIVIDUAL NPI
2	1609159533	OTHER	CA	TYPE 2 NPI

General Provider Information

NPI Number	:	1609149533
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENDALL S WOOLRIDGE D,D,S PC

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	:	310-648-8776

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	:	310-648-8776

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	KENDALL SHERRON WOOLRIDGE
Credential	:	DDS
Telephone Number	:	310-648-8781

Provider Enumeration Date	:	02/23/2012
Last Update Date	:	10/05/2021

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