Basic Information
| Provider Information | |||||||||
| NPI: | 1912423690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMKO | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2817 REILLY ST STOP B | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712315383 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2817 REILLY ST | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712315383 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2017 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 33149 | TX | N | Dental Providers | Dentist | 1223G0001X | 33149 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.