Provider Demographics
NPI:1942499207
Name:MICKENS, PRENARD RAINEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRENARD
Middle Name:RAINEY
Last Name:MICKENS
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 1:300 W 135TH ST APT 7D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2760
Mailing Address - Country:US
Mailing Address - Phone:212-234-6978
Mailing Address - Fax:
Practice Address - Street 1:1416 YANCEYVILLE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6955
Practice Address - Country:US
Practice Address - Phone:917-805-8509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC76371223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics