Provider Demographics
NPI:1134241185
Name:KENNEDY, WADE ALEXANDER (DMD)
Entity type:Individual
Prefix:DR
First Name:WADE
Middle Name:ALEXANDER
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 1:5745 ERINDALE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-8926
Mailing Address - Country:US
Mailing Address - Phone:719-599-7665
Mailing Address - Fax:719-599-8599
Practice Address - Street 1:5745 ERINDALE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-8926
Practice Address - Country:US
Practice Address - Phone:719-599-7665
Practice Address - Fax:719-599-8599
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO60541223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics