Provider Demographics
NPI:1568764769
Name:JASON KENNON DMD LLC
Entity Type:Organization
Organization Name:JASON KENNON DMD LLC
Other - Org Name:KENNON DENTAL ASSOCIATES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:BRANCH
Authorized Official - Last Name:KENNON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-769-1034
Mailing Address - Street 1:2309 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2171
Mailing Address - Country:US
Mailing Address - Phone:850-769-1034
Mailing Address - Fax:850-769-6898
Practice Address - Street 1:2309 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2171
Practice Address - Country:US
Practice Address - Phone:850-769-1034
Practice Address - Fax:850-769-6898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL159951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty