Provider Demographics
NPI:1164615050
Name:WEEKS, KENNON CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNON
Middle Name:CHARLES
Last Name:WEEKS
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 1:2415 W VERNON AVE
Mailing Address - Street 2:CASWELL CENTER
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504-3337
Mailing Address - Country:US
Mailing Address - Phone:252-208-4074
Mailing Address - Fax:252-208-4080
Practice Address - Street 1:2415 W VERNON AVE
Practice Address - Street 2:CASWELL CENTER
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-3337
Practice Address - Country:US
Practice Address - Phone:252-208-4074
Practice Address - Fax:252-208-4080
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC45471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU42878Medicaid