Provider Demographics
NPI:1326107004
Name:KENNEDY, KEITH D (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:D
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 S POWER RD STE 128
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-9283
Mailing Address - Country:US
Mailing Address - Phone:480-225-9769
Mailing Address - Fax:
Practice Address - Street 1:7400 S POWER RD STE 128
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-9283
Practice Address - Country:US
Practice Address - Phone:480-225-9769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD56711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ201797682OtherTAX ID #
AZ895401OtherAHCCCS
AZ1689938OtherUNITED CONCORDIA
AZAZ0413330OtherBLUE CROSS BLUE SHIELD