Provider Demographics
NPI:1700266236
Name:KENNEDY, ANN DOUGLAS (DDS)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:DOUGLAS
Last Name:KENNEDY
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 1:16607 RIVERSTONE WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-5750
Mailing Address - Country:US
Mailing Address - Phone:336-209-2974
Mailing Address - Fax:
Practice Address - Street 1:16607 RIVERSTONE WAY STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-544-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100821223P0221X, 122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program