Provider Demographics
NPI:1457827180
Name:MOYNIHAN, KATHERINE ELIZABETH
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:MOYNIHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1104
Mailing Address - Country:US
Mailing Address - Phone:508-498-6171
Mailing Address - Fax:
Practice Address - Street 1:322 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1104
Practice Address - Country:US
Practice Address - Phone:508-498-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-20
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18581821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program