Healthcare Provider Details

I. General information

NPI: 1033270970
Provider Name (Legal Business Name): KENNEDY DENTAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38924 COAL RIVER RD.
WHITESVILLE WV
25209
US

IV. Provider business mailing address

PO BOX 776
WHITESVILLE WV
25209-0776
US

V. Phone/Fax

Practice location:
  • Phone: 304-854-2110
  • Fax: 304-854-2111
Mailing address:
  • Phone: 304-854-2110
  • Fax: 304-854-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY A. DILLON
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 304-744-9717