Provider Demographics
NPI:1780607812
Name:JEFFREY R KENNEDY DDS PA
Entity type:Organization
Organization Name:JEFFREY R KENNEDY DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-967-9291
Mailing Address - Street 1:123 FRANKLIN STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516
Mailing Address - Country:US
Mailing Address - Phone:919-967-9291
Mailing Address - Fax:919-942-4446
Practice Address - Street 1:123 FRANKLIN STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516
Practice Address - Country:US
Practice Address - Phone:919-967-9291
Practice Address - Fax:919-942-4446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0137NOtherBCBS
NC89902KFMedicaid
NC89902KFMedicaid