Provider Demographics
NPI:1124162144
Name:AHEARN, DAVID J (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:AHEARN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 VILLAGE WAY
Mailing Address - Street 2:P O BOX 3629
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790
Mailing Address - Country:US
Mailing Address - Phone:508-636-6566
Mailing Address - Fax:508-636-6587
Practice Address - Street 1:302 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-0702
Practice Address - Country:US
Practice Address - Phone:508-636-6566
Practice Address - Fax:508-636-6587
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16036122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11461OtherBLUE CROSS PROVIDER