Provider Demographics
NPI:1962709956
Name:TISDALE, KENNETH DORSEY (LCICI, LMT #548)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DORSEY
Last Name:TISDALE
Suffix:
Gender:M
Credentials:LCICI, LMT #548
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 MENAUL BLVD
Mailing Address - Street 2:8400 MENAUL BLVD. NE. #217
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112
Mailing Address - Country:US
Mailing Address - Phone:505-712-7585
Mailing Address - Fax:
Practice Address - Street 1:201 EUBANK BLVD NE
Practice Address - Street 2:B1
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123
Practice Address - Country:US
Practice Address - Phone:505-712-7585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLMT # 5488171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor