Healthcare Provider Details

I. General information

NPI: 1801471297
Provider Name (Legal Business Name): ALICIA NICOLE KENNEDY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5835 E STILL CIR
MESA AZ
85206-3618
US

IV. Provider business mailing address

10136 E SOUTHERN AVE UNIT 3084
MESA AZ
85209-2755
US

V. Phone/Fax

Practice location:
  • Phone: 480-248-8107
  • Fax:
Mailing address:
  • Phone: 860-883-3792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: