Provider Demographics
NPI:1285720391
Name:KENNEDY, RICHARD GEORGE (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GEORGE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27180 NEWPORT RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7389
Mailing Address - Country:US
Mailing Address - Phone:951-679-9355
Mailing Address - Fax:951-301-0130
Practice Address - Street 1:27180 NEWPORT ROAD SUITE 1
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-2248
Practice Address - Country:US
Practice Address - Phone:951-679-9355
Practice Address - Fax:951-301-0130
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34502122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330892037OtherTIN#