Provider Demographics
NPI:1003850256
Name:KENNEDY & RICHARDSON DENTAL OFFICE
Entity Type:Organization
Organization Name:KENNEDY & RICHARDSON DENTAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-744-9717
Mailing Address - Street 1:1000 PARKWAY RD
Mailing Address - Street 2:STE. D
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-9418
Mailing Address - Country:US
Mailing Address - Phone:304-744-9717
Mailing Address - Fax:304-744-9733
Practice Address - Street 1:1000 PARKWAY RD
Practice Address - Street 2:STE. D
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-9418
Practice Address - Country:US
Practice Address - Phone:304-744-9717
Practice Address - Fax:304-744-9733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty