MEDICARE: KELLY A. HENNESSEY D.D.S., 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1710634670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY A. HENNESSEY D.D.S., PLLC

Provider Business Mailing Address
First Line	:	3615 S GRAND BLVD
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99203-2624
Country	:	US
Telephone Number	:	509-456-8676
Fax Number	:	509-465-8676

Provider Business Practice Location Address
First Line	:	3615 S GRAND BLVD
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99203-2624
Country	:	US
Telephone Number	:	509-456-8676
Fax Number	:	509-465-8676

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	KELLY A HENNESSEY
Credential	:	DDS
Telephone Number	:	509-714-5757

Provider Enumeration Date	:	03/09/2022
Last Update Date	:	03/09/2022

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