Provider Demographics
NPI:1508245663
Name:THOMAS KENNEDY, DDS OF MISSOURI II, LLC
Entity Type:Organization
Organization Name:THOMAS KENNEDY, DDS OF MISSOURI II, LLC
Other - Org Name:DENTURES AND DENTAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-733-8551
Mailing Address - Street 1:2609 N KANSAS EXPY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-1114
Mailing Address - Country:US
Mailing Address - Phone:417-501-8922
Mailing Address - Fax:
Practice Address - Street 1:2609 N KANSAS EXPY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-1114
Practice Address - Country:US
Practice Address - Phone:417-501-8922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11904122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty