Provider Demographics
NPI:1275387342
Name:KENNEDY, MICHAEL (DMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S HOPE ST APT 1708
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-4715
Mailing Address - Country:US
Mailing Address - Phone:646-409-7412
Mailing Address - Fax:
Practice Address - Street 1:6905 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-3646
Practice Address - Country:US
Practice Address - Phone:323-863-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA110900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program