Provider Demographics
NPI:1083788715
Name:KENNEDY, JORDAN BRENT (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:BRENT
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 1:4675 E SR 44
Mailing Address - Street 2:#104
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-7461
Mailing Address - Country:US
Mailing Address - Phone:352-418-3041
Mailing Address - Fax:
Practice Address - Street 1:4675 E SR 44
Practice Address - Street 2:#104
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-7461
Practice Address - Country:US
Practice Address - Phone:352-418-3041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN177151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice