Healthcare Provider Details

I. General information

NPI: 1629366604
Provider Name (Legal Business Name): MOIRA KENNEDY CASEY D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 09/16/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 LYNN FELLS PKWY
MELROSE MA
02176
US

IV. Provider business mailing address

540 LYNN FELLS PKWY
MELROSE MA
02176-2327
US

V. Phone/Fax

Practice location:
  • Phone: 781-665-1355
  • Fax:
Mailing address:
  • Phone: 781-665-1355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN1856182
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: