Provider Demographics
NPI:1821155896
Name:KENNEDY, MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
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 1:4252 N VERRADO WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-7586
Mailing Address - Country:US
Mailing Address - Phone:602-214-5479
Mailing Address - Fax:623-594-8120
Practice Address - Street 1:4252 N VERRADO WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-7586
Practice Address - Country:US
Practice Address - Phone:602-214-5479
Practice Address - Fax:623-594-8120
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD59101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice