Healthcare Provider Details

I. General information

NPI: 1407049612
Provider Name (Legal Business Name): KENNEDY FAMILY DENTISTRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 EXECUTIVE CT STE 200
SACRAMENTO CA
95864-2648
US

IV. Provider business mailing address

1611 EXECUTIVE CT STE 200
SACRAMENTO CA
95864-2648
US

V. Phone/Fax

Practice location:
  • Phone: 916-487-5160
  • Fax:
Mailing address:
  • Phone: 916-487-5160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number35625
License Number StateCA

VIII. Authorized Official

Name: MRS. TIFFANY MONIQUE SETTLE
Title or Position: OFFICE MANAGER
Credential: OM
Phone: 916-487-5152