Provider Demographics
NPI:1972701498
Name:STILTS, KENNETH WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:STILTS
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 1:660 MANZANITA DR
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-3806
Mailing Address - Country:US
Mailing Address - Phone:805-528-0770
Mailing Address - Fax:
Practice Address - Street 1:545 MAIN ST
Practice Address - Street 2:SUITE B-2
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-2522
Practice Address - Country:US
Practice Address - Phone:805-772-2731
Practice Address - Fax:805-772-2733
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA212891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice