MEDICARE: KENNEDY MARZONIE GRAY & ASSOCIATES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12814	MI
2	122300000X	Dentist	12824	MI
3	122300000X	Dentist	18447	MI

General Provider Information

NPI Number	:	1154430718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNEDY MARZONIE GRAY & ASSOCIATES PLLC

Provider Business Mailing Address
First Line	:	2365 S HURON PKWY
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-5156
Country	:	US
Telephone Number	:	734-677-8700
Fax Number	:	734-839-4137

Provider Business Practice Location Address
First Line	:	2365 S HURON PKWY
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-5156
Country	:	US
Telephone Number	:	734-677-8700
Fax Number	:	348-394-1377

Authorized Official
Title or Position	:	BILLING AND MARKETING MANAGER
Name	:	SHARENE NICOLE RUMOHR
Credential	:
Telephone Number	:	734-677-8700

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	08/01/2022

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