Provider Demographics
NPI:1669031654
Name:VINCENT, KEARA (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEARA
Middle Name:
Last Name:VINCENT
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 1:445 MICA CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6461
Mailing Address - Country:US
Mailing Address - Phone:757-771-4657
Mailing Address - Fax:
Practice Address - Street 1:1915 W PARK DR STE 104
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3777
Practice Address - Country:US
Practice Address - Phone:336-903-9399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11420122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist