Healthcare Provider Details

I. General information

NPI: 1669462941
Provider Name (Legal Business Name): KEVIN D JENNINGS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 PROVIDENCE RD SUITE 11
CHESAPEAKE VA
23325-4687
US

IV. Provider business mailing address

211 PROVIDENCE RD SUITE 11
CHESAPEAKE VA
23325-4687
US

V. Phone/Fax

Practice location:
  • Phone: 757-523-9002
  • Fax: 757-523-9005
Mailing address:
  • Phone: 757-523-9002
  • Fax: 757-523-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6444
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: