Provider Demographics
NPI:1942792379
Name:TAKACH, KATHLEEN (DMD, MPH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:TAKACH
Suffix:
Gender:F
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MORGAN DR UNIT 35
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1484
Mailing Address - Country:US
Mailing Address - Phone:207-253-9434
Mailing Address - Fax:
Practice Address - Street 1:326 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-1914
Practice Address - Country:US
Practice Address - Phone:978-878-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00205494122300000X
NH044071223G0001X
MADN1858901122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice