Provider Demographics
NPI:1952716466
Name:KELLEHER, REBECCA MOOAR (DDS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MOOAR
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 HOPMEADOW ST
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-2462
Mailing Address - Country:US
Mailing Address - Phone:860-658-0010
Mailing Address - Fax:
Practice Address - Street 1:573 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-2462
Practice Address - Country:US
Practice Address - Phone:860-658-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT112011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program