Provider Demographics
NPI:1962697318
Name:JOSEPH R. KENNEALLY, DMD, PA
Entity type:Organization
Organization Name:JOSEPH R. KENNEALLY, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:KENNEALLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-283-1752
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME28761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty