Provider Demographics
NPI:1285687947
Name:MERRITT, KENNEDY WOOD (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNEDY
Middle Name:WOOD
Last Name:MERRITT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5855 W UTOPIA RD
Mailing Address - Street 2:MIDWESTERN UNIVERSITY DENTAL INSTITUTE
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5251
Mailing Address - Country:US
Mailing Address - Phone:623-537-6080
Mailing Address - Fax:623-537-6013
Practice Address - Street 1:5855 W UTOPIA RD
Practice Address - Street 2:MIDWESTERN UNIVERSITY DENTAL INSTITUTE
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5251
Practice Address - Country:US
Practice Address - Phone:623-806-7070
Practice Address - Fax:623-537-6013
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1246122300000X
AZD009344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00089243Medicaid