Provider Demographics
NPI:1518191170
Name:KEVIN P. HAGERTY DMD PC
Entity Type:Organization
Organization Name:KEVIN P. HAGERTY DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:HAGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-884-4874
Mailing Address - Street 1:61 CEDAR AVENUE, #5
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818
Mailing Address - Country:US
Mailing Address - Phone:401-884-4874
Mailing Address - Fax:401-884-4928
Practice Address - Street 1:61 CEDAR AVE UNIT 5
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-3190
Practice Address - Country:US
Practice Address - Phone:401-884-4874
Practice Address - Fax:401-884-4928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI21551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI8048-6OtherBLUE CROSS RI DENTAL
RIKH00257Medicaid
RI8048-6OtherBLUE CROSS RI DENTAL