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NPI Code Detail

MEDICARE: DR. WADE ALEXANDER KENNEDY DMD

MEDICARE: DR. WADE ALEXANDER KENNEDY DMD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223E0200XEndodontics6054CO

General Provider Information

NPI Number : 1134241185
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. WADE ALEXANDER KENNEDY DMD
Provider Business Mailing Address
First Line : 5745 ERINDALE DR
Second Line : SUITE 200
City : COLORADO SPRINGS
State : CO
Zip : 80918-8926
Country : US
Telephone Number : 719-599-7665
Fax Number : 719-599-8599
Provider Business Practice Location Address
First Line : 5745 ERINDALE DR
Second Line : SUITE 200
City : COLORADO SPRINGS
State : CO
Zip : 80918-8926
Country : US
Telephone Number : 719-599-7665
Fax Number : 719-599-8599
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/03/2007
Last Update Date : 07/08/2007

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