Provider Demographics
NPI:1568679298
Name:WISHART, KENNETH DONOVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DONOVAN
Last Name:WISHART
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 1:6111 JOHNSON CT
Mailing Address - Street 2:STE. 201
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3331
Mailing Address - Country:US
Mailing Address - Phone:925-924-9900
Mailing Address - Fax:
Practice Address - Street 1:6111 JOHNSON CT
Practice Address - Street 2:STE. 201
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-3331
Practice Address - Country:US
Practice Address - Phone:925-924-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33901122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist