Provider Demographics
NPI:1588718746
Name:PATTERSOM, KENNETH E (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:PATTERSOM
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 1:1411 FILLMORE ST STE 601
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3343
Mailing Address - Country:US
Mailing Address - Phone:208-733-2300
Mailing Address - Fax:208-736-7214
Practice Address - Street 1:1411 FILLMORE ST STE 601
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3343
Practice Address - Country:US
Practice Address - Phone:208-733-2300
Practice Address - Fax:208-736-7214
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1788122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002288154Medicaid
ID001184500Medicaid