Provider Demographics
NPI:1124263884
Name:COVENTRY ORTHODONTIC LLC
Entity type:Organization
Organization Name:COVENTRY ORTHODONTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KACEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-884-6500
Mailing Address - Street 1:2435 NOOSENECK HILL RD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816
Mailing Address - Country:US
Mailing Address - Phone:401-397-9400
Mailing Address - Fax:401-397-9402
Practice Address - Street 1:2435 NOOSENECK HILL RD
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816
Practice Address - Country:US
Practice Address - Phone:401-397-9400
Practice Address - Fax:401-397-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI26421223X0400X
RI30011223X0400X
RI17161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty