Provider Demographics
NPI:1427494350
Name:KEPHART, NICKOLAS ANDREW (DDS)
Entity type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:ANDREW
Last Name:KEPHART
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3962
Mailing Address - Country:US
Mailing Address - Phone:336-760-9840
Mailing Address - Fax:
Practice Address - Street 1:3165 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3962
Practice Address - Country:US
Practice Address - Phone:336-760-9840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-19
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice