Provider Demographics
NPI:1407049612
Name:KENNEDY FAMILY DENTISTRY, INC
Entity Type:Organization
Organization Name:KENNEDY FAMILY DENTISTRY, INC
Other - Org Name:DR. BOBBY C. KENNEDY, DDS.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:SETTLE
Authorized Official - Suffix:
Authorized Official - Credentials:OM
Authorized Official - Phone:916-487-5152
Mailing Address - Street 1:1611 EXECUTIVE CT STE 200
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-2648
Mailing Address - Country:US
Mailing Address - Phone:916-487-5160
Mailing Address - Fax:
Practice Address - Street 1:1611 EXECUTIVE CT STE 200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95864-2648
Practice Address - Country:US
Practice Address - Phone:916-487-5160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35625302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization