Healthcare Provider Details

I. General information

NPI: 1275195166
Provider Name (Legal Business Name): KIERSTEN DENISE BETHEA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 FAYETTEVILLE ST
DURHAM NC
27707-2325
US

IV. Provider business mailing address

5119 CARLSON DAIRY RD
SUMMERFIELD NC
27358-9210
US

V. Phone/Fax

Practice location:
  • Phone: 919-956-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number11493
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11493
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: