Provider Demographics
NPI:1841330990
Name:KAVANAGH, DAVID A (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:KAVANAGH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15808 MILL CREEK BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1500
Mailing Address - Country:US
Mailing Address - Phone:425-745-0931
Mailing Address - Fax:425-316-0395
Practice Address - Street 1:15808 MILL CREEK BLVD STE 130
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1500
Practice Address - Country:US
Practice Address - Phone:425-745-0931
Practice Address - Fax:425-316-0395
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA68631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice