Provider Demographics
NPI:1588170112
Name:THOMAS KENNEDY, DDS OF LOUISIANA II, A PROFESSIONAL DENTAL LLC
Entity type:Organization
Organization Name:THOMAS KENNEDY, DDS OF LOUISIANA II, A PROFESSIONAL DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HALEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-733-8551
Mailing Address - Street 1:170 NORTHSHORE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-6820
Mailing Address - Country:US
Mailing Address - Phone:985-500-3155
Mailing Address - Fax:985-643-6987
Practice Address - Street 1:170 NORTHSHORE BLVD STE B
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-6820
Practice Address - Country:US
Practice Address - Phone:985-500-3155
Practice Address - Fax:985-643-6987
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THOMAS JOHN KENNEDY OF LOUISIANA, DDS, PROFESSIONAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-19
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1857688Medicaid