Provider Demographics
NPI:1215088166
Name:MACPHERSON, KENNETH SCOTT (LD LICENSED DENTURIS)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:SCOTT
Last Name:MACPHERSON
Suffix:
Gender:M
Credentials:LD LICENSED DENTURIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 KENSINGTON AVE
Mailing Address - Street 2:#25B
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801
Mailing Address - Country:US
Mailing Address - Phone:406-542-0609
Mailing Address - Fax:406-721-7617
Practice Address - Street 1:715 KENSINGTON AVE
Practice Address - Street 2:#25B
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-542-0609
Practice Address - Fax:406-721-7617
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT18122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0150241Medicaid