Provider Demographics
NPI:1538350038
Name:WALLIS, KENNETH GREGG (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GREGG
Last Name:WALLIS
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 1:265 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-6503
Mailing Address - Country:US
Mailing Address - Phone:408-248-6777
Mailing Address - Fax:408-248-1947
Practice Address - Street 1:265 CRESTVIEW DR
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-6503
Practice Address - Country:US
Practice Address - Phone:408-248-6777
Practice Address - Fax:408-248-1947
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA349141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice