Provider Demographics
NPI:1376576207
Name:POOLE, KENNETH ALEXANDER II (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALEXANDER
Last Name:POOLE
Suffix:II
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 1:4020 DUPLIN DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-7763
Mailing Address - Country:US
Mailing Address - Phone:336-315-0943
Mailing Address - Fax:
Practice Address - Street 1:2835 HORSE PEN CREEK RD STE 106
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-9700
Practice Address - Country:US
Practice Address - Phone:336-662-0807
Practice Address - Fax:336-662-0828
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC60811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996986Medicaid
AL810-41OtherBCBS OF ALABAMA
PA864646OtherPENN. BLUE SHIELD
TN40706OtherBCBS OF TENN.
NC96986OtherBCBS PROVIDER #
TXV0068OtherBCBS OF TEXAS