Provider Demographics
NPI:1942218227
Name:PEACOCK, KENT L (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:L
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 N TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-2649
Mailing Address - Country:US
Mailing Address - Phone:432-332-5175
Mailing Address - Fax:432-332-2886
Practice Address - Street 1:1601 N TEXAS AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-2649
Practice Address - Country:US
Practice Address - Phone:432-332-5175
Practice Address - Fax:432-332-2886
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice