Provider Demographics
NPI:1578458675
Name:WILLSON, KYNNEDY B (DDS)
Entity type:Individual
Prefix:
First Name:KYNNEDY
Middle Name:B
Last Name:WILLSON
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 1:2385 BUCKSIDE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-3292
Mailing Address - Country:US
Mailing Address - Phone:337-499-0155
Mailing Address - Fax:
Practice Address - Street 1:310 E CENTERTON BLVD
Practice Address - Street 2:
Practice Address - City:CENTERTON
Practice Address - State:AR
Practice Address - Zip Code:72719-9217
Practice Address - Country:US
Practice Address - Phone:479-579-3742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR48491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice