Provider Demographics
NPI:1124146022
Name:WHITWORTH, KENNETH B (DDS, MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:WHITWORTH
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45485 EAGLE CREST LN
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-1843
Mailing Address - Country:US
Mailing Address - Phone:951-694-6667
Mailing Address - Fax:
Practice Address - Street 1:41619 MARGARITA RD STE 102
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-2986
Practice Address - Country:US
Practice Address - Phone:951-676-4473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD427841223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology