Provider Demographics
NPI:1710349048
Name:KENNEDY, LORI TOLOSO (EDDA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:TOLOSO
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:EDDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10454 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7965
Mailing Address - Country:US
Mailing Address - Phone:318-277-0309
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant