Provider Demographics
NPI:1821838004
Name:MOORE, KENNEDY (DMD)
Entity type:Individual
Prefix:DR
First Name:KENNEDY
Middle Name:
Last Name:MOORE
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 1:89 WACHUSETT ST APT 3
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4462
Mailing Address - Country:US
Mailing Address - Phone:585-412-3025
Mailing Address - Fax:
Practice Address - Street 1:100 HIGH ST STE 200
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090-1196
Practice Address - Country:US
Practice Address - Phone:781-733-9378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN10000242122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist