Provider Demographics
NPI:1194900555
Name:CHANDA A. KENNEMER, DDS, PC
Entity type:Organization
Organization Name:CHANDA A. KENNEMER, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHANDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KENNEMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-533-1233
Mailing Address - Street 1:1405 S SANGRE RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1832
Mailing Address - Country:US
Mailing Address - Phone:405-533-1233
Mailing Address - Fax:
Practice Address - Street 1:1405 S SANGRE RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1832
Practice Address - Country:US
Practice Address - Phone:405-533-1233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty