Provider Demographics
NPI:1689755837
Name:KAVANAGH, JOHN RICHARD (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:R
Other - Last Name:KAVANAGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:3731 TIBBETTS STREET
Mailing Address - Street 2:SUITE 10
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92606
Mailing Address - Country:US
Mailing Address - Phone:951-683-4790
Mailing Address - Fax:951-683-4795
Practice Address - Street 1:3731 TIBBETTS ST
Practice Address - Street 2:SUITE 10
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2604
Practice Address - Country:US
Practice Address - Phone:951-683-4790
Practice Address - Fax:951-683-4795
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA484781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics