Provider Demographics
NPI:1982772026
Name:KENNEDY, CRISTINA PELLICANO (DMD)
Entity Type:Individual
Prefix:
First Name:CRISTINA
Middle Name:PELLICANO
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 1:501 NE HOOD AVE STE 235
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7346
Mailing Address - Country:US
Mailing Address - Phone:503-661-4900
Mailing Address - Fax:503-667-3856
Practice Address - Street 1:501 NE HOOD AVE STE 235
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7346
Practice Address - Country:US
Practice Address - Phone:503-661-4900
Practice Address - Fax:503-667-3856
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice