=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124263884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVENTRY ORTHODONTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2008
-----------------------------------------------------
Last Update Date | 12/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2435 NOOSENECK HILL RD
-----------------------------------------------------
City | COVENTRY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-397-9400
-----------------------------------------------------
Fax | 401-397-9402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2435 NOOSENECK HILL RD
-----------------------------------------------------
City | COVENTRY
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-397-9400
-----------------------------------------------------
Fax | 401-397-9402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. JOHN S KACEWICZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-884-6500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 2642
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 3001
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 1716
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------