Healthcare Provider Details

I. General information

NPI: 1689755837
Provider Name (Legal Business Name): JOHN RICHARD KAVANAGH D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JACK R KAVANAGH D.D.S., M.S.

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3731 TIBBETTS ST SUITE 10
RIVERSIDE CA
92506-2604
US

IV. Provider business mailing address

3731 TIBBETTS STREET SUITE 10
RIVERSIDE CA
92606
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-4790
  • Fax: 951-683-4795
Mailing address:
  • Phone: 951-683-4790
  • Fax: 951-683-4795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number48478
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: