Provider Demographics
NPI:1366438509
Name:KENNEALLY, JOSEPH R (DMD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:R
Last Name:KENNEALLY
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 1:6 WELLSPRING RD
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9415
Mailing Address - Country:US
Mailing Address - Phone:207-283-1752
Mailing Address - Fax:207-283-1415
Practice Address - Street 1:6 WELLSPRING RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9415
Practice Address - Country:US
Practice Address - Phone:207-283-1752
Practice Address - Fax:207-283-1415
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME28761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice