Provider Demographics
NPI:1073650016
Name:KENNEDY, PAMELA (RDH)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 E MAIN ST
Mailing Address - Street 2:3RD FLOOR DENTAL HYGIENE
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-2335
Mailing Address - Country:US
Mailing Address - Phone:203-576-7441
Mailing Address - Fax:203-576-8311
Practice Address - Street 1:752 E MAIN ST
Practice Address - Street 2:3RD FLOOR DENTAL HYGIENE
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-2335
Practice Address - Country:US
Practice Address - Phone:203-576-7441
Practice Address - Fax:203-576-8311
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003678124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT9175945Medicare UPIN
CT184905Medicare UPIN