Provider Demographics
NPI:1194933721
Name:KENNEDY, ROBERT A (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 BERLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-4121
Mailing Address - Country:US
Mailing Address - Phone:860-667-8186
Mailing Address - Fax:860-667-8179
Practice Address - Street 1:2434 BERLIN TPKE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-4121
Practice Address - Country:US
Practice Address - Phone:860-667-8186
Practice Address - Fax:860-667-8179
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020004762CT011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice