Provider Demographics
NPI:1780733865
Name:KAVANAGH, SHELAGH MIRIAM (DMD)
Entity type:Individual
Prefix:DR
First Name:SHELAGH
Middle Name:MIRIAM
Last Name:KAVANAGH
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 1:59 CODDINGTON ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-472-3700
Mailing Address - Fax:617-472-1793
Practice Address - Street 1:59 CODDINGTON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-472-3700
Practice Address - Fax:617-472-1793
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA193791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice