Healthcare Provider Details

I. General information

NPI: 1760116818
Provider Name (Legal Business Name): GREGORY L. KENNEDY D.M.D PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12475 US HIGHWAY 90
GRAND BAY AL
36541-5796
US

IV. Provider business mailing address

PO BOX 628
GRAND BAY AL
36541-0628
US

V. Phone/Fax

Practice location:
  • Phone: 251-865-3500
  • Fax: 251-865-1101
Mailing address:
  • Phone: 251-865-3500
  • Fax: 251-865-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY L KENNEDY
Title or Position: DOCTOR / OWNER
Credential: DMD
Phone: 251-865-3500