Provider Demographics
NPI:1154413128
Name:BROWN, KENNETH RANDALL (DENTIST)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RANDALL
Last Name:BROWN
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10960 WINDS CROSSING DRIVE SUITE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273
Mailing Address - Country:US
Mailing Address - Phone:704-588-7542
Mailing Address - Fax:704-588-7595
Practice Address - Street 1:10960 WINDS CROSSING DRIVE SUITE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273
Practice Address - Country:US
Practice Address - Phone:704-588-7542
Practice Address - Fax:704-588-7595
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC58971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice