Provider Demographics
NPI:1891347951
Name:KENNEDY, ALEXANDRA RICKER (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:RICKER
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ALEXANDRA
Other - Last Name:RICKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS MS
Mailing Address - Street 1:3805 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9421
Mailing Address - Country:US
Mailing Address - Phone:903-581-2900
Mailing Address - Fax:903-509-0160
Practice Address - Street 1:3805 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9421
Practice Address - Country:US
Practice Address - Phone:903-581-2900
Practice Address - Fax:903-509-0160
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX356801223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty