Provider Demographics
NPI:1184607731
Name:TANKERSLEY, KENNETH LEE (DDS AND MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:TANKERSLEY
Suffix:
Gender:M
Credentials:DDS AND MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 THORPES PARISH
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-5119
Mailing Address - Country:US
Mailing Address - Phone:757-345-6979
Mailing Address - Fax:
Practice Address - Street 1:716 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4414
Practice Address - Country:US
Practice Address - Phone:757-874-6501
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8000590Medicaid
VA466101OtherANTHEM
VA01464599OtherUNITED CONCORDIA
VA8000590Medicaid
VA002445D43Medicare ID - Type Unspecified