Provider Demographics
NPI:1487797254
Name:KAVANAUGH, JACK (MD,DDS)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:KAVANAUGH
Suffix:
Gender:M
Credentials:MD,DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19019 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE # 100 B
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-1524
Mailing Address - Country:US
Mailing Address - Phone:310-371-0113
Mailing Address - Fax:310-371-1927
Practice Address - Street 1:19019 HAWTHORNE BLVD
Practice Address - Street 2:SUITE # 100 B
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1524
Practice Address - Country:US
Practice Address - Phone:310-371-0113
Practice Address - Fax:310-371-1927
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA233301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice