Provider Demographics
NPI:1336106525
Name:KENWORTHY, PAUL FRANCIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:FRANCIS
Last Name:KENWORTHY
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 1:1 KENNEDY DR # LL4
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7152
Mailing Address - Country:US
Mailing Address - Phone:888-720-5832
Mailing Address - Fax:888-965-5114
Practice Address - Street 1:1 KENNEDY DR # LL4
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7152
Practice Address - Country:US
Practice Address - Phone:888-720-5832
Practice Address - Fax:888-965-5114
Is Sole Proprietor?:No
Enumeration Date:2006-04-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-00009751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002551Medicaid
VTY400189729OtherMEDICARE ID # ASSOCIATED WITH A REASSIGNMENT OF BENEFITS