Provider Demographics
NPI:1043405590
Name:AUSTIN, KENNETH LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3694 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-7081
Mailing Address - Country:US
Mailing Address - Phone:662-842-8035
Mailing Address - Fax:662-842-3018
Practice Address - Street 1:3694 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-7081
Practice Address - Country:US
Practice Address - Phone:662-842-8035
Practice Address - Fax:662-842-3018
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2988-97122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043405590OtherDELTA DENTAL