Provider Demographics
NPI:1891984365
Name:MASSARELLI, KEVIN JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
Last Name:MASSARELLI
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 1:178 MOUNT BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-5147
Mailing Address - Country:US
Mailing Address - Phone:908-647-8577
Mailing Address - Fax:
Practice Address - Street 1:178 MOUNT BETHEL RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5147
Practice Address - Country:US
Practice Address - Phone:908-647-8577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI15267122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist