Provider Demographics
NPI:1932476140
Name:BAMPO ADDO, KYEREMAA (RDH)
Entity Type:Individual
Prefix:
First Name:KYEREMAA
Middle Name:
Last Name:BAMPO ADDO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28A BOSTON AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-1948
Mailing Address - Country:US
Mailing Address - Phone:508-459-9060
Mailing Address - Fax:
Practice Address - Street 1:32 CONCORD ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8302
Practice Address - Country:US
Practice Address - Phone:508-270-2635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADH87654124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110022061EOtherMEDICAID GROUP NUMBER