Provider Demographics
NPI:1649633470
Name:KEVON E. RENNIE DMD, P.A.
Entity type:Organization
Organization Name:KEVON E. RENNIE DMD, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVON
Authorized Official - Middle Name:E
Authorized Official - Last Name:RENNIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-495-0881
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:315-454-6000
Mailing Address - Fax:315-410-5531
Practice Address - Street 1:1747 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4238
Practice Address - Country:US
Practice Address - Phone:904-495-0881
Practice Address - Fax:904-824-9257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN213991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty