Provider Demographics
NPI:1447394556
Name:PEAVY, KENNETH ALTON (DMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALTON
Last Name:PEAVY
Suffix:
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 1:1400 WESTGATE CENTER DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3104
Mailing Address - Country:US
Mailing Address - Phone:336-774-3001
Mailing Address - Fax:336-774-9161
Practice Address - Street 1:1400 WESTGATE CENTER DR
Practice Address - Street 2:SUITE 204
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3104
Practice Address - Country:US
Practice Address - Phone:336-774-3001
Practice Address - Fax:336-774-9161
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC58761223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics