Basic Information
| Provider Information | |||||||||
| NPI: | 1487843066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THOMAS KENNEDY, DDS OF MISSOURI II, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5863 SUEMANDY DR | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633764327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369701460 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5863 SUEMANDY DR | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633764327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369701460 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2007 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | WOOSTER | ||||||||
| AuthorizedOfficialFirstName: | HALEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7127338551 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 011904 | MO | N | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.