Provider Demographics
NPI:1578901229
Name:KENNY ROAD FAMILY DENTAL
Entity Type:Organization
Organization Name:KENNY ROAD FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-451-2727
Mailing Address - Street 1:4589 KENNY ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220
Mailing Address - Country:US
Mailing Address - Phone:614-451-2727
Mailing Address - Fax:614-451-8177
Practice Address - Street 1:4589 KENNY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2770
Practice Address - Country:US
Practice Address - Phone:614-451-2727
Practice Address - Fax:614-451-8177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30016420122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty