Provider Demographics
NPI:1417009382
Name:ROARK, KINESHIA ABRAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:KINESHIA
Middle Name:ABRAM
Last Name:ROARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KINESHIA
Other - Middle Name:ABRAM
Other - Last Name:ABRAM-ROARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:113 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3304
Mailing Address - Country:US
Mailing Address - Phone:601-602-4142
Mailing Address - Fax:
Practice Address - Street 1:3720 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1550
Practice Address - Country:US
Practice Address - Phone:601-264-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3533-101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice