Provider Demographics
NPI:1013132604
Name:FRAGA, KENNETH JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOSEPH
Last Name:FRAGA
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 1:401 GREGORY LN
Mailing Address - Street 2:#222
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523
Mailing Address - Country:US
Mailing Address - Phone:925-687-0343
Mailing Address - Fax:925-687-4711
Practice Address - Street 1:401 GREGORY LN
Practice Address - Street 2:#222
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523
Practice Address - Country:US
Practice Address - Phone:925-687-0343
Practice Address - Fax:925-687-4711
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA411741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice