Provider Demographics
NPI:1861557308
Name:KENWORTHY, CHRISTIAN RANDALL (DDS, MS)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:RANDALL
Last Name:KENWORTHY
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 1:690 SW HIGGINS AVE STE F
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1433
Mailing Address - Country:US
Mailing Address - Phone:406-721-2796
Mailing Address - Fax:
Practice Address - Street 1:690 SW HIGGINS AVE STE F
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1433
Practice Address - Country:US
Practice Address - Phone:406-721-2796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics