Provider Demographics
NPI:1306926407
Name:MYRBERG, KENNETH JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAMES
Last Name:MYRBERG
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 1:1204 A W SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-1554
Mailing Address - Country:US
Mailing Address - Phone:712-246-2180
Mailing Address - Fax:712-246-1683
Practice Address - Street 1:1204 A W SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-1554
Practice Address - Country:US
Practice Address - Phone:712-246-2180
Practice Address - Fax:712-246-1683
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5587122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist