Provider Demographics
NPI:1295778454
Name:KENNAN, KELLY SUSAN (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:SUSAN
Last Name:KENNAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 BELMONT AVE SUITE 204
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:410-742-4339
Mailing Address - Fax:410-742-4388
Practice Address - Street 1:1322 BELMONT AVE SUITE 204
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-742-4339
Practice Address - Fax:410-742-4388
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD125991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice