Provider Demographics
NPI:1568673366
Name:KENNEDY, KELLY SUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:SUE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:SUE
Other - Last Name:KREUTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:305 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1267
Mailing Address - Country:US
Mailing Address - Phone:614-292-5574
Mailing Address - Fax:614-292-9472
Practice Address - Street 1:305 W 12TH AVE
Practice Address - Street 2:DENTAL FACULTY PRACTICE
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:614-292-5574
Practice Address - Fax:614-292-9472
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0227171223S0112X
OH23221223S0112X
OH30.022717204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery