Provider Demographics
NPI:1760562490
Name:KENNEDY, DANIEL JACOB (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACOB
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 1:2365 S HURON PKWY
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5156
Mailing Address - Country:US
Mailing Address - Phone:734-677-8700
Mailing Address - Fax:734-839-4137
Practice Address - Street 1:2365 S HURON PKWY
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5156
Practice Address - Country:US
Practice Address - Phone:734-677-8700
Practice Address - Fax:734-839-4137
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI12814122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BK8276948OtherDEA