Healthcare Provider Details

I. General information

NPI: 1720197536
Provider Name (Legal Business Name): DR. ROBERT FORD KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 LONE TREE WAY 7
ANTIOCH CA
94509-6067
US

IV. Provider business mailing address

3524 SPRINGHILL RD
LAFAYETTE CA
94549-2536
US

V. Phone/Fax

Practice location:
  • Phone: 925-756-7884
  • Fax: 925-756-7890
Mailing address:
  • Phone: 925-284-2635
  • Fax: 925-284-2685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number16790
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: