Provider Demographics
NPI:1073246815
Name:KENNEDY, TIMOTHY RYAN (DMD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RYAN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3740 SOUTH 14TH ST
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS-MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1667 COCHRANE CIR BLDG 7495
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4603
Practice Address - Country:US
Practice Address - Phone:719-526-5537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY107591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY10759OtherDENTAL LICENSE