Provider Demographics
NPI:1386780328
Name:EVINS, KENNETH (DENTIST)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:EVINS
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 1:107 INDUSTRIAL DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549
Mailing Address - Country:US
Mailing Address - Phone:919-496-8132
Mailing Address - Fax:919-496-3123
Practice Address - Street 1:107 INDUSTRIAL DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549
Practice Address - Country:US
Practice Address - Phone:919-496-8132
Practice Address - Fax:919-496-3123
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC46361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC07101OtherHEALTH CHOICE
NC3404486Medicaid
NC81111DOtherPRIVATE INS