Provider Demographics
NPI:1033959036
Name:KENNEDY, SEAN P (DMD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:P
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 GREENDALE CT
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1940
Mailing Address - Country:US
Mailing Address - Phone:608-436-2988
Mailing Address - Fax:
Practice Address - Street 1:720 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-1271
Practice Address - Country:US
Practice Address - Phone:715-532-7054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI600151715122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist