Provider Demographics
NPI:1194051961
Name:KENWORTHY, MARK WILLIAM (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:KENWORTHY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14785 JEFFREY RD.,
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-0408
Mailing Address - Country:US
Mailing Address - Phone:949-551-2606
Mailing Address - Fax:949-551-1904
Practice Address - Street 1:14785 JEFFREY RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-0408
Practice Address - Country:US
Practice Address - Phone:949-551-2606
Practice Address - Fax:949-551-1904
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28012122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist