Provider Demographics
NPI:1003252917
Name:DINE, KENLY LEWIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENLY
Middle Name:LEWIS
Last Name:DINE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 RAMSEY ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-7672
Mailing Address - Country:US
Mailing Address - Phone:910-670-6321
Mailing Address - Fax:
Practice Address - Street 1:4140 RAMSEY ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-7672
Practice Address - Country:US
Practice Address - Phone:910-670-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-18
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9496122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist