Provider Demographics
NPI:1780032136
Name:KASENCHAK, MARY JO (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY JO
Middle Name:
Last Name:KASENCHAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 CECIL B MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-4014
Mailing Address - Country:US
Mailing Address - Phone:215-320-6187
Mailing Address - Fax:
Practice Address - Street 1:2144 CECIL B MOORE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-4014
Practice Address - Country:US
Practice Address - Phone:215-320-6187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist