Healthcare Provider Details

I. General information

NPI: 1790137131
Provider Name (Legal Business Name): TAYLOR KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 INTERNATIONAL CIR SUITE 100
COLORADO SPRINGS CO
80910-3127
US

IV. Provider business mailing address

3205 N ACADEMY BLVD STE 130
COLORADO SPRINGS CO
80917-5147
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-5700
  • Fax:
Mailing address:
  • Phone: 719-632-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDEN.00201915
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: