Provider Demographics
NPI:1578613865
Name:KEVIN P MOONEY DDS PC
Entity Type:Organization
Organization Name:KEVIN P MOONEY DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:781-932-5999
Mailing Address - Street 1:3 BALDWIN GREEN CMN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1865
Mailing Address - Country:US
Mailing Address - Phone:781-932-5999
Mailing Address - Fax:781-935-4804
Practice Address - Street 1:3 BALDWIN GREEN CMN
Practice Address - Street 2:SUITE 101
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1865
Practice Address - Country:US
Practice Address - Phone:781-932-5999
Practice Address - Fax:781-935-4804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA167491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11819OtherBLUE CROSS BLUE SHIELD
MA709783OtherUNITED CONCORDIA