Provider Demographics
NPI:1972637130
Name:KANOY, BURRELL EDMOND JR (DDS, MA)
Entity Type:Individual
Prefix:DR
First Name:BURRELL
Middle Name:EDMOND
Last Name:KANOY
Suffix:JR
Gender:M
Credentials:DDS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3400 CROASDAILE DR
Mailing Address - Street 2:SUITE 209
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-6815
Mailing Address - Country:US
Mailing Address - Phone:919-383-7020
Mailing Address - Fax:919-383-3141
Practice Address - Street 1:3400 CROASDAILE DR
Practice Address - Street 2:SUITE 209
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-6815
Practice Address - Country:US
Practice Address - Phone:919-383-7020
Practice Address - Fax:919-383-3141
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC45001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8994772Medicaid