Provider Demographics
NPI:1619092194
Name:BLOCK, KENDRA DOREEN (DDS)
Entity type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:DOREEN
Last Name:BLOCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SEWARD LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3108
Mailing Address - Country:US
Mailing Address - Phone:631-689-0415
Mailing Address - Fax:
Practice Address - Street 1:213 HALLOCK RD
Practice Address - Street 2:SUITE 1
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3000
Practice Address - Country:US
Practice Address - Phone:631-689-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042182122300000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No122300000XDental ProvidersDentist