MEDICARE: DR. CHARLES A. KENNEDY DDS

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	2816	WV

General Provider Information

NPI Number	:	1790896199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES A. KENNEDY DDS

Provider Business Mailing Address
First Line	:	PO BOX 58400
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25358-0400
Country	:	US
Telephone Number	:	304-744-9717
Fax Number	:	304-744-9733

Provider Business Practice Location Address
First Line	:	1000 PARKWAY RD
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-9418
Country	:	US
Telephone Number	:	304-744-9717
Fax Number	:	304-744-9733

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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