Provider Demographics
NPI:1548360001
Name:WOOD, KEN I (DDS MS)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:I
Last Name:WOOD
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1369
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1369
Mailing Address - Country:US
Mailing Address - Phone:870-931-5437
Mailing Address - Fax:870-931-9781
Practice Address - Street 1:2702 CULBERHOUSE
Practice Address - Street 2:SOUTHWEST VILLAGE
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-931-5437
Practice Address - Fax:870-931-9781
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR27381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
828134OtherUNITED CONCORDIA
59239OtherBLUE CROSS BLUE SHIELD