MEDICARE: DR. KENNEDY WOOD MERRITT D.D.S.

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
1	122300000X	Dentist	DD1246	NM
2	122300000X	Dentist	D009344	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285687947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNEDY WOOD MERRITT D.D.S.

Provider Business Mailing Address
First Line	:	5855 W UTOPIA RD
Second Line	:	MIDWESTERN UNIVERSITY DENTAL INSTITUTE
City	:	GLENDALE
State	:	AZ
Zip	:	85308-5251
Country	:	US
Telephone Number	:	623-537-6080
Fax Number	:	623-537-6013

Provider Business Practice Location Address
First Line	:	5855 W UTOPIA RD
Second Line	:	MIDWESTERN UNIVERSITY DENTAL INSTITUTE
City	:	GLENDALE
State	:	AZ
Zip	:	85308-5251
Country	:	US
Telephone Number	:	623-806-7070
Fax Number	:	623-537-6013

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	12/09/2015

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