Provider Demographics
NPI:1770729253
Name:KENDRICK & JONES DENTAL, LLC
Entity type:Organization
Organization Name:KENDRICK & JONES DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-525-6872
Mailing Address - Street 1:1226 N LEDLIE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-2542
Mailing Address - Country:US
Mailing Address - Phone:217-525-6872
Mailing Address - Fax:
Practice Address - Street 1:1226 N LEDLIE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-2542
Practice Address - Country:US
Practice Address - Phone:217-525-6872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190164761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty