Provider Demographics
NPI:1477195261
Name:KENNEDY, CHRISTINE ELIZABETH (EPDH)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ELIZABETH
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3514 22ND CT SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-5875
Mailing Address - Country:US
Mailing Address - Phone:541-619-7232
Mailing Address - Fax:
Practice Address - Street 1:3000 MARKET ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1882
Practice Address - Country:US
Practice Address - Phone:503-917-2604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-13
Last Update Date:2019-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7637124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist