Healthcare Provider Details

I. General information

NPI: 1104238716
Provider Name (Legal Business Name): JARED KENNEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2014
Last Update Date: 12/28/2024
Certification Date: 12/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21300 N JOHN WAYNE PKWY STE 114
MARICOPA AZ
85139
US

IV. Provider business mailing address

3232 E REDWOOD LN
PHOENIX AZ
85048-7834
US

V. Phone/Fax

Practice location:
  • Phone: 520-231-6700
  • Fax: 520-208-9066
Mailing address:
  • Phone: 916-204-8762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD009960
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: