Provider Demographics
NPI:1750271698
Name:KENNEDY, ANNA MARIN
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ANNA
Other - Middle Name:MARIN
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:4502 NICKLAUS DR APT 261
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1509
Mailing Address - Country:US
Mailing Address - Phone:541-310-9717
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2501
Practice Address - Country:US
Practice Address - Phone:217-383-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018.0123001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty