Healthcare Provider Details

I. General information

NPI: 1518151935
Provider Name (Legal Business Name): JASON ROBERT KENNEDY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1858 CREST RD
MARYVILLE TN
37804-4305
US

IV. Provider business mailing address

301 LAKE FOREST DR
KNOXVILLE TN
37920-5146
US

V. Phone/Fax

Practice location:
  • Phone: 865-977-7110
  • Fax:
Mailing address:
  • Phone: 865-577-0361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberN/A (RESIDENT)
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: