Provider Demographics
NPI:1780123356
Name:KENNEDY, SCOTT (DMD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S AVENUE Q
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:TX
Mailing Address - Zip Code:76634-1825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 S AVENUE Q
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:TX
Practice Address - Zip Code:76634-1825
Practice Address - Country:US
Practice Address - Phone:254-675-3518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX332581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program