Provider Demographics
NPI:1982969242
Name:KINCANNON, LAURA K (DDS)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:K
Last Name:KINCANNON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:KATHERINE
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:907 S. COLUMBIA DR.
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:TX
Mailing Address - Zip Code:77486
Mailing Address - Country:US
Mailing Address - Phone:979-345-1451
Mailing Address - Fax:979-345-4205
Practice Address - Street 1:907 S. COLUMBIA DR.
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:TX
Practice Address - Zip Code:77486
Practice Address - Country:US
Practice Address - Phone:979-345-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX279501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice