Provider Demographics
NPI:1518488808
Name:KENNEDY, STEVEN WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:WAYNE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5306 CHAPARRAL DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1230
Mailing Address - Country:US
Mailing Address - Phone:907-460-1525
Mailing Address - Fax:
Practice Address - Street 1:4000 BELLMEAD DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-3138
Practice Address - Country:US
Practice Address - Phone:254-799-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX337651223G0001X
ORD10667122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist