Provider Demographics
NPI:1023280344
Name:KENNEDY, GABRIEL M (DMD)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 24TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-7539
Mailing Address - Country:US
Mailing Address - Phone:541-924-9000
Mailing Address - Fax:541-926-1036
Practice Address - Street 1:1040 24TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-7539
Practice Address - Country:US
Practice Address - Phone:541-924-9000
Practice Address - Fax:541-926-1036
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD89161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery