Provider Demographics
NPI:1447311451
Name:KENNEDY DENTAL OFFICE
Entity type:Organization
Organization Name:KENNEDY DENTAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-744-9717
Mailing Address - Street 1:410 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:WV
Mailing Address - Zip Code:25136-2105
Mailing Address - Country:US
Mailing Address - Phone:304-442-2488
Mailing Address - Fax:304-442-8835
Practice Address - Street 1:410 4TH AVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:WV
Practice Address - Zip Code:25136-2105
Practice Address - Country:US
Practice Address - Phone:304-442-2488
Practice Address - Fax:304-442-8835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty