Provider Demographics
NPI:1558533315
Name:MICHAEL C. KINNEBREW, MD, DDS, PA
Entity Type:Organization
Organization Name:MICHAEL C. KINNEBREW, MD, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:O
Authorized Official - Last Name:BELISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-762-2618
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC960001541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8949309Medicaid
NC145230OtherGUARDIAN
NC8994921Medicaid
NC979443OtherUCCI
NC49309OtherBCBS
NC979443OtherUCCI