Healthcare Provider Details

I. General information

NPI: 1275387342
Provider Name (Legal Business Name): MICHAEL KENNEDY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2024
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 E GRAND AVE STE 102
EL SEGUNDO CA
90245-3871
US

IV. Provider business mailing address

1201 S HOPE ST APT 1706
LOS ANGELES CA
90015-4699
US

V. Phone/Fax

Practice location:
  • Phone: 424-209-6902
  • Fax:
Mailing address:
  • Phone: 213-800-6021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number110900
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: