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General NPI Number Information
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NPI Number | 1518151935
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Entity Type | Individual
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Provider Name | JASON ROBERT KENNEDY D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/29/2007
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Last Update Date | 06/04/2008
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Provider Practice Location Address
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Address Line | 1858 CREST RD
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City | MARYVILLE
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State | TN
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Zip | 37804-4305
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Country | US
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Telephone | 865-977-7110
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Fax |
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Provider Business Mailing Address
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Address Line | 301 LAKE FOREST DR
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City | KNOXVILLE
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State | TN
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Zip | 37920-5146
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Country | US
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Telephone | 865-577-0361
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | N/A (RESIDENT)
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License Number State | TN
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