Provider Demographics
NPI:1013926955
Name:KENNEL, DIETMAR A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIETMAR
Middle Name:A
Last Name:KENNEL
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 1:5601 COUNTY ROAD 1440
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-5785
Mailing Address - Country:US
Mailing Address - Phone:806-438-0481
Mailing Address - Fax:806-368-9984
Practice Address - Street 1:1504 BUDDY HOLLY AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-5131
Practice Address - Country:US
Practice Address - Phone:806-749-5437
Practice Address - Fax:806-744-7241
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX192641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1112112-02Medicaid