Provider Demographics
NPI:1982897989
Name:KENNEDY, JULIE MARIE (DDS)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 44TH ST S.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-235-2860
Mailing Address - Fax:701-235-4179
Practice Address - Street 1:3170 44TH ST S.
Practice Address - Street 2:SUITE 100
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104
Practice Address - Country:US
Practice Address - Phone:701-235-2860
Practice Address - Fax:701-235-4179
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND124361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice