Basic Information
| Provider Information | |||||||||
| NPI: | 1003015496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILTBANK | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | BYRON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 320 A AVENUE | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036363383 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 320 A AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970343056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036363383 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D7468 | OR | Y | Dental Providers | Dentist |
No ID Information.