Provider Demographics
NPI:1699804492
Name:KENNEDY, BOBBY CARL (DDS)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:CARL
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:BOBBY
Other - Middle Name:CARL
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1611 EXECUTIVE CT STE 200
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-2648
Mailing Address - Country:US
Mailing Address - Phone:916-487-5160
Mailing Address - Fax:916-487-8332
Practice Address - Street 1:1611 EXECUTIVE CT STE 200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95864-2648
Practice Address - Country:US
Practice Address - Phone:916-487-5160
Practice Address - Fax:916-487-8332
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA356251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3562501Medicaid