MEDICARE: KAITLIN KENNEDY RDH

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	124Q00000X	Dental Hygienist	30597	CA

General Provider Information

NPI Number	:	1205407772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLIN KENNEDY RDH

Provider Business Mailing Address
First Line	:	24011 LINDLEY ST
Second Line	:
City	:	MISSION VIEJO
State	:	CA
Zip	:	92691-3716
Country	:	US
Telephone Number	:	916-532-4030
Fax Number	:

Provider Business Practice Location Address
First Line	:	29861 SANTA MARGARITA PKWY STE 200
Second Line	:
City	:	RANCHO SANTA MARGARITA
State	:	CA
Zip	:	92688-3624
Country	:	US
Telephone Number	:	714-709-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2021
Last Update Date	:	07/06/2021

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