Healthcare Provider Details

I. General information

NPI: 1720008568
Provider Name (Legal Business Name): PAUL A KENNEDY, JR., D.D.S., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 SARATOGA BLVD
CORPUS CHRISTI TX
78414-3421
US

IV. Provider business mailing address

6200 SARATOGA BLVD BUILDING 1
CORPUS CHRISTI TX
78414-3477
US

V. Phone/Fax

Practice location:
  • Phone: 361-992-9500
  • Fax: 361-992-1862
Mailing address:
  • Phone: 361-992-9500
  • Fax: 361-992-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8445
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8445
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8445
License Number StateTX

VIII. Authorized Official

Name: DR. PAUL A KENNEDY
Title or Position: PRESIDENT
Credential: DDS
Phone: 361-992-9500