Provider Demographics
NPI:1083761282
Name:EUBANKS, KEVIN GLENN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GLENN
Last Name:EUBANKS
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 1:148 WATERLOO ST SW STE 2
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-3766
Mailing Address - Country:US
Mailing Address - Phone:803-641-3883
Mailing Address - Fax:
Practice Address - Street 1:148 WATERLOO ST SW STE 2
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3766
Practice Address - Country:US
Practice Address - Phone:803-641-3883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3587122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist