Healthcare Provider Details

I. General information

NPI: 1013552579
Provider Name (Legal Business Name): KEVIN DRISCOLL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 WICKER ST STE A
SANFORD NC
27330-4168
US

IV. Provider business mailing address

14 ALLEN CT
STATEN ISLAND NY
10310-2703
US

V. Phone/Fax

Practice location:
  • Phone: 718-689-0169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12633
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number13182
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: