MEDICARE: JASON KENNON DMD LLC

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	1223G0001X	General Practice Dentistry	15995	FL

General Provider Information

NPI Number	:	1568764769
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JASON KENNON DMD LLC

Provider Business Mailing Address
First Line	:	2309 SAINT ANDREWS BLVD
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2171
Country	:	US
Telephone Number	:	850-769-1034
Fax Number	:	850-769-6898

Provider Business Practice Location Address
First Line	:	2309 SAINT ANDREWS BLVD
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-2171
Country	:	US
Telephone Number	:	850-769-1034
Fax Number	:	850-769-6898

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JASON BRANCH KENNON
Credential	:	DMD
Telephone Number	:	850-769-1034

Provider Enumeration Date	:	11/22/2010
Last Update Date	:	12/22/2010

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