Provider Demographics
NPI:1326128877
Name:FALLON, KEVIN GLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GLEN
Last Name:FALLON
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 1:39 GROVE ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1408
Mailing Address - Country:US
Mailing Address - Phone:603-924-6731
Mailing Address - Fax:603-924-0982
Practice Address - Street 1:39 GROVE ST
Practice Address - Street 2:SUITE 7
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1408
Practice Address - Country:US
Practice Address - Phone:603-924-6731
Practice Address - Fax:603-924-0982
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3230122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist