Provider Demographics
NPI:1326112970
Name:DERRICK, KENDRA DAWN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:DAWN
Last Name:DERRICK
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 1:3833 ROSWELL RD NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4432
Mailing Address - Country:US
Mailing Address - Phone:404-261-6794
Mailing Address - Fax:
Practice Address - Street 1:3833 ROSWELL RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4432
Practice Address - Country:US
Practice Address - Phone:404-261-6794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0122591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice