MEDICARE: DR. BRIAN JOSEPH KENNEDY DDS

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	PD0032	AZ

General Provider Information

NPI Number	:	1376152991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN JOSEPH KENNEDY DDS

Provider Business Mailing Address
First Line	:	3250 S ARIZONA AVE APT 3034
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85248-2739
Country	:	US
Telephone Number	:	310-701-5027
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 W CHANDLER BLVD STE 22
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224-6175
Country	:	US
Telephone Number	:	480-681-1946
Fax Number	:

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

Provider Enumeration Date	:	07/29/2020
Last Update Date	:	07/29/2020

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