Provider Demographics
NPI:1013441831
Name:OBI-GWACHAM, KAYCEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAYCEE
Middle Name:
Last Name:OBI-GWACHAM
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 1:19810 W CATAWBA AVE # A1
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4056
Mailing Address - Country:US
Mailing Address - Phone:910-644-2884
Mailing Address - Fax:
Practice Address - Street 1:2200 WALTERS DIVISION RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110
Practice Address - Country:US
Practice Address - Phone:704-289-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC111391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty