Provider Demographics
NPI:1194912576
Name:REYES, KENNETH DIMAGMALIW (DDS)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DIMAGMALIW
Last Name:REYES
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:PO BOX 5215
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-5215
Mailing Address - Country:US
Mailing Address - Phone:510-323-5002
Mailing Address - Fax:
Practice Address - Street 1:3980 SAN PABLO DAM RD
Practice Address - Street 2:SUITE 202
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-2840
Practice Address - Country:US
Practice Address - Phone:510-323-5002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA481731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice