Provider Demographics
NPI:1811568561
Name:CLARKSVILLE TONGUE TIE CENTER PLLC
Entity Type:Organization
Organization Name:CLARKSVILLE TONGUE TIE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-206-0852
Mailing Address - Street 1:590 FIRE STATION RD STE D
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4076
Mailing Address - Country:US
Mailing Address - Phone:931-444-3410
Mailing Address - Fax:
Practice Address - Street 1:590 FIRE STATION RD STE D
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4076
Practice Address - Country:US
Practice Address - Phone:931-444-3410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNO INSURANCE