Provider Demographics
NPI:1982806592
Name:KENNA, THERESA D (DMD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:D
Last Name:KENNA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:K
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:201 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-1304
Mailing Address - Country:US
Mailing Address - Phone:270-877-2011
Mailing Address - Fax:270-877-2030
Practice Address - Street 1:201 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-1304
Practice Address - Country:US
Practice Address - Phone:270-877-2011
Practice Address - Fax:270-877-2030
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY68071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60068079Medicaid