Provider Demographics
NPI:1093832917
Name:KAVANAGH, THOMAS E (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:KAVANAGH
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 1:1417 MARLOWE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4318
Mailing Address - Country:US
Mailing Address - Phone:216-221-7500
Mailing Address - Fax:216-221-2430
Practice Address - Street 1:1417 MARLOWE AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4318
Practice Address - Country:US
Practice Address - Phone:216-221-7500
Practice Address - Fax:216-221-2430
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH170981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0499929Medicaid