Provider Demographics
NPI:1316031560
Name:KENNEDY DENTAL LLC
Entity Type:Organization
Organization Name:KENNEDY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-642-3434
Mailing Address - Street 1:202 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1261
Mailing Address - Country:US
Mailing Address - Phone:937-642-3434
Mailing Address - Fax:937-642-6434
Practice Address - Street 1:202 E 5TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1261
Practice Address - Country:US
Practice Address - Phone:937-642-3434
Practice Address - Fax:937-642-6434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17367122300000X
OH17486122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty