Provider Demographics
NPI:1376942573
Name:KENNEDY, KRISTI NICOLE JOHNSON (DDS, MPH)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:NICOLE JOHNSON
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48TH MEDICAL GROUP, RAF LAKENHEATH
Mailing Address - Street 2:UNIT 5115
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:09461-5115
Mailing Address - Country:US
Mailing Address - Phone:314-226-8317
Mailing Address - Fax:
Practice Address - Street 1:48TH MEDICAL GROUP, RAF LAKENHEATH
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:09461-5115
Practice Address - Country:US
Practice Address - Phone:314-226-8317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX299221223G0001X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice