Healthcare Provider Details

I. General information

NPI: 1538129978
Provider Name (Legal Business Name): JOHN R KASHMANIAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 EVERETT STREET
SOUTHBRIDGE MA
01550
US

IV. Provider business mailing address

55 EVERETT STREET
SOUTHBRIDGE MA
01550
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-0099
  • Fax: 508-765-0091
Mailing address:
  • Phone: 508-765-0099
  • Fax: 508-765-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number0016765
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number007615
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: