Provider Demographics
NPI:1669541819
Name:KENNEDY, DENNIS (OD, FAAO)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4426
Mailing Address - Country:US
Mailing Address - Phone:707-546-3836
Mailing Address - Fax:
Practice Address - Street 1:208 E ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4426
Practice Address - Country:US
Practice Address - Phone:707-546-3836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5412T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0054120Medicaid
CA0950410001OtherCIGNA PIN
CASD0054120Medicaid
CASD0054121Medicare PIN