Provider Demographics
NPI:1346238862
Name:KINNEBREW, MICHAEL CLARK (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CLARK
Last Name:KINNEBREW
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7305
Mailing Address - Country:US
Mailing Address - Phone:910-762-2618
Mailing Address - Fax:910-763-5173
Practice Address - Street 1:1122 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7305
Practice Address - Country:US
Practice Address - Phone:910-762-2618
Practice Address - Fax:910-763-5173
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC960001541223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10272203OtherVOCATIONAL REHABILITATION
NC8949309Medicaid
NC49309OtherBLUE CROSS BLUE SHIELD
979443OtherUNITED CONCORDIA
NC8994921Medicaid
979443OtherUNITED CONCORDIA
NC10272203OtherVOCATIONAL REHABILITATION