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General NPI Number Information
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NPI Number | 1811568561
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Entity Type | Organization
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Legal Business Name | CLARKSVILLE TONGUE TIE CENTER PLLC
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Dates
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Enumeration Date | 07/05/2021
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Last Update Date | 07/05/2021
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Provider Practice Location Address
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Address Line | 590 FIRE STATION RD STE D
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City | CLARKSVILLE
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State | TN
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Zip | 37043-4076
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Country | US
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Telephone | 931-444-3410
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Fax |
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Provider Business Mailing Address
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Address Line | 590 FIRE STATION RD STE D
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City | CLARKSVILLE
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State | TN
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Zip | 37043-4076
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Country | US
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Telephone | 931-444-3410
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KEVIN KENNEDY JR.
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Credential | DDS
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Telephone | 931-206-0852
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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