Provider Demographics
NPI:1306852868
Name:PHILLIPS, KENNETH R (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:PHILLIPS
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:27103-3919
Mailing Address - Country:US
Mailing Address - Phone:336-760-9840
Mailing Address - Fax:336-760-9841
Practice Address - Street 1:3165 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3919
Practice Address - Country:US
Practice Address - Phone:336-760-9840
Practice Address - Fax:336-760-9841
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC96865OtherBCBS
NC466090OtherUNITED CONCORDIA
NC8996865Medicaid