Provider Demographics
NPI:1174546675
Name:PIERSON, KENNETH WAYNE (DDS, MPH)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:PIERSON
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1979 HILLMAN ST
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-1601
Mailing Address - Country:US
Mailing Address - Phone:559-732-4279
Mailing Address - Fax:559-636-4455
Practice Address - Street 1:1979 HILLMAN ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-1601
Practice Address - Country:US
Practice Address - Phone:559-732-4279
Practice Address - Fax:559-636-4455
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22015122300000X
CAGA10451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000222015CAOtherDELTA DENTAL OF CA
CAB22015-01OtherDENTI-CAL PROVIDER ID