Basic Information
| Provider Information | |||||||||
| NPI: | 1578613865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEVIN P MOONEY DDS PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3 BALDWIN GREEN CMN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018011865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819325999 | ||||||||
| FaxNumber: | 7819354804 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 BALDWIN GREEN CMN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018011865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819325999 | ||||||||
| FaxNumber: | 7819354804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 09/18/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOONEY | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7819325999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 16749 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | X11819 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 709783 | 01 | MA | UNITED CONCORDIA | OTHER |