Provider Demographics
NPI:1558921932
Name:BRAXTON, KERBY ROXANNE (DDS)
Entity Type:Individual
Prefix:
First Name:KERBY
Middle Name:ROXANNE
Last Name:BRAXTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 JASPER BLVD
Mailing Address - Street 2:
Mailing Address - City:SULLIVANS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29482-9614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 CHURCH ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2405
Practice Address - Country:US
Practice Address - Phone:843-520-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110271223G0001X
SC93601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice