Provider Demographics
NPI:1487611406
Name:SMITH, KENNETH J (DDS)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:SMITH
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 1:504 SKAGGS RD
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-8852
Mailing Address - Country:US
Mailing Address - Phone:606-784-7679
Mailing Address - Fax:606-784-4408
Practice Address - Street 1:709 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1443
Practice Address - Country:US
Practice Address - Phone:606-784-8983
Practice Address - Fax:606-784-4408
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4300122300000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60043007Medicaid
KY64043003Medicaid
T78540Medicare UPIN
KY64043003Medicaid