Provider Demographics
NPI:1538183900
Name:NELSON, KENNETH W (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:NELSON
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 1:1919 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3405
Mailing Address - Country:US
Mailing Address - Phone:316-634-1414
Mailing Address - Fax:316-634-2907
Practice Address - Street 1:1919 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3405
Practice Address - Country:US
Practice Address - Phone:316-634-1414
Practice Address - Fax:316-634-2907
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS51491223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100097110AMedicaid
KST44047Medicare UPIN
KS100097110AMedicaid