Provider Demographics
NPI:1265519227
Name:KADDIS, MINA JOSEPH (DMD)
Entity type:Individual
Prefix:DR
First Name:MINA
Middle Name:JOSEPH
Last Name:KADDIS
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 1:6 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760
Mailing Address - Country:US
Mailing Address - Phone:508-653-3930
Mailing Address - Fax:508-653-1261
Practice Address - Street 1:6 DEWEY ST
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760
Practice Address - Country:US
Practice Address - Phone:508-653-3930
Practice Address - Fax:508-653-1261
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21602122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2123584Medicaid