Provider Demographics
NPI:1679648521
Name:KENNEDY DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:KENNEDY DENTAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:J
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-291-3535
Mailing Address - Street 1:1411 JF KENNEDY DRIVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-3693
Mailing Address - Country:US
Mailing Address - Phone:402-291-3535
Mailing Address - Fax:402-291-0760
Practice Address - Street 1:1411 JF KENNEDY DRIVE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3693
Practice Address - Country:US
Practice Address - Phone:402-291-3535
Practice Address - Fax:402-291-0760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========13Medicaid