Healthcare Provider Details

I. General information

NPI: 1336223395
Provider Name (Legal Business Name): GREGORY LYNN KENNEDY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12475 US HIGHWAY 90
GRAND BAY AL
36541-5707
US

IV. Provider business mailing address

PO BOX 629
GRAND BAY AL
36541-0629
US

V. Phone/Fax

Practice location:
  • Phone: 251-865-3500
  • Fax:
Mailing address:
  • Phone: 251-865-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3862
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: