Individual
DR. KENNETH WAYNE VANSICKLE JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.M.D
Contact information
Practice address
2008 SAINT MICHAELS DR, SUITE B, SANTA FE, NM 87505-7682
(505) 474-4993
(505) 474-4973
Mailing address
16 ARCADE UNIT 198747, NASHVILLE, TN 37219-1994
(615) 750-0343
(615) 986-1705
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DD2304
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
160531
UNITED CONCORDIA
NM
05
—
52823083
—
NM
05
—
9177992
—
NM
Enumeration date
12/29/2005
Last updated
04/23/2013
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