Provider Demographics
NPI:1184746851
Name:PALM, KENNETH (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:PALM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:
Other - Last Name:PALM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:106 HIGH POINT CTR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-8800
Mailing Address - Country:US
Mailing Address - Phone:802-655-5308
Mailing Address - Fax:
Practice Address - Street 1:106 HIGH POINT CTR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5861
Practice Address - Country:US
Practice Address - Phone:802-655-5308
Practice Address - Fax:802-655-5715
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT012371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT412187837OtherTAX IDENTIFICATION NUMBER
VT1005081Medicaid