Provider Demographics
NPI:1942536891
Name:KENNY, DOUGLAS A, (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A,
Last Name:KENNY
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 1:260 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:OH
Mailing Address - Zip Code:44041-1807
Mailing Address - Country:US
Mailing Address - Phone:440-466-2202
Mailing Address - Fax:
Practice Address - Street 1:260 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-1807
Practice Address - Country:US
Practice Address - Phone:440-466-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0194311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice