Provider Demographics
NPI:1962227371
Name:KENEDY DENTAL PLLC
Entity type:Organization
Organization Name:KENEDY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MAXIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-838-3772
Mailing Address - Street 1:PO BOX 195487
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-8608
Mailing Address - Country:US
Mailing Address - Phone:972-838-3772
Mailing Address - Fax:
Practice Address - Street 1:131 BUSINESS PARK BLVD STE 600
Practice Address - Street 2:
Practice Address - City:KENEDY
Practice Address - State:TX
Practice Address - Zip Code:78119-3512
Practice Address - Country:US
Practice Address - Phone:972-838-3772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental