Provider Demographics
NPI:1922214691
Name:KENNEDY, ROSELYN BROOKS (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROSELYN
Middle Name:BROOKS
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:ROSELYN
Other - Middle Name:
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2041 SILAS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5147
Mailing Address - Country:US
Mailing Address - Phone:336-777-0303
Mailing Address - Fax:336-777-3448
Practice Address - Street 1:1400 WALTER REED RD
Practice Address - Street 2:STE 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4411
Practice Address - Country:US
Practice Address - Phone:910-864-9884
Practice Address - Fax:910-354-1399
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300192281223P0221X
NC83651223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0102838Medicaid