Provider Demographics
NPI:1255816104
Name:SPRING CREEK PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:SPRING CREEK PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:931-206-0852
Mailing Address - Street 1:590 FIRE STATION RD STE C
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4016
Mailing Address - Country:US
Mailing Address - Phone:931-648-9930
Mailing Address - Fax:
Practice Address - Street 1:590 FIRE STATION RD STE C
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4016
Practice Address - Country:US
Practice Address - Phone:931-648-9930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-26
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527793Medicaid