Provider Demographics
NPI:1598876260
Name:TROMBLY, KEVIN LOUIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LOUIS
Last Name:TROMBLY
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 1:1575 WILBRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01119
Mailing Address - Country:US
Mailing Address - Phone:413-783-2582
Mailing Address - Fax:413-783-2583
Practice Address - Street 1:1575 WILBRAHAM RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01119
Practice Address - Country:US
Practice Address - Phone:413-783-2582
Practice Address - Fax:413-783-2583
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA132411223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0250724Medicaid
MATRX04117Medicare ID - Type Unspecified
T57172Medicare UPIN