Provider Demographics
NPI:1972614329
Name:SMALL, KENNETH NEIL (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:NEIL
Last Name:SMALL
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 1:446 ROUTE 304
Mailing Address - Street 2:
Mailing Address - City:BARDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:10954-1617
Mailing Address - Country:US
Mailing Address - Phone:845-623-6666
Mailing Address - Fax:845-623-6748
Practice Address - Street 1:446 ROUTE 304
Practice Address - Street 2:
Practice Address - City:BARDONIA
Practice Address - State:NY
Practice Address - Zip Code:10954-1617
Practice Address - Country:US
Practice Address - Phone:845-623-6666
Practice Address - Fax:845-623-6748
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339071223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics