Provider Demographics
NPI:1316084239
Name:KENYON, PEGGY SUE (RDH)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:SUE
Last Name:KENYON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 ALDEN DR
Mailing Address - Street 2:
Mailing Address - City:FT WARREN AFB
Mailing Address - State:WY
Mailing Address - Zip Code:82005-3906
Mailing Address - Country:US
Mailing Address - Phone:307-773-1846
Mailing Address - Fax:307-773-3550
Practice Address - Street 1:6900 ALDEN DR
Practice Address - Street 2:
Practice Address - City:FT WARREN AFB
Practice Address - State:WY
Practice Address - Zip Code:82005-3906
Practice Address - Country:US
Practice Address - Phone:307-773-1846
Practice Address - Fax:307-773-3550
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY633124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist