Provider Demographics
NPI:1629399647
Name:KENNEDY, KEVIN CHAMBLISS JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHAMBLISS
Last Name:KENNEDY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2858 SUMMER LAWN DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4030
Mailing Address - Country:US
Mailing Address - Phone:931-648-9930
Mailing Address - Fax:
Practice Address - Street 1:590 FIRE STATION RD STE C
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4016
Practice Address - Country:US
Practice Address - Phone:931-648-9930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN94111223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527793Medicaid