Provider Demographics
NPI:1679685853
Name:KENNEDY, JOHNNY DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:DALE
Last Name:KENNEDY
Suffix:
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 1:1911 CONGRESS PKWY
Mailing Address - Street 2:PO BOX 1029
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37371-1029
Mailing Address - Country:US
Mailing Address - Phone:423-745-2630
Mailing Address - Fax:423-745-2632
Practice Address - Street 1:1911 CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303
Practice Address - Country:US
Practice Address - Phone:423-745-2630
Practice Address - Fax:423-745-2632
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS34591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice