Provider Demographics
NPI:1770777104
Name:KENNEDY, NICOLA C (DMD)
Entity type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:C
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MAIN ST, 8TH FLOOR
Mailing Address - Street 2:HARTFORD BOARD OF ED HEALTH SERVICES
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06103
Mailing Address - Country:US
Mailing Address - Phone:860-695-4005
Mailing Address - Fax:
Practice Address - Street 1:960 MAIN ST, 8TH FLOOR
Practice Address - Street 2:HARTFORD BOARD OF ED HEALTH SERVICES
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06103
Practice Address - Country:US
Practice Address - Phone:860-695-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008653122300000X, 1223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice