MEDICARE: PAUL KENWORTHY DMD, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	000016975	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124441720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL KENWORTHY DMD, PC

Provider Business Mailing Address
First Line	:	4 KELLOGG RD
Second Line	:
City	:	ESSEX JCT
State	:	VT
Zip	:	05452-2815
Country	:	US
Telephone Number	:	802-879-5151
Fax Number	:	866-561-8426

Provider Business Practice Location Address
First Line	:	4 KELLOGG RD
Second Line	:
City	:	ESSEX JCT
State	:	VT
Zip	:	05452-2815
Country	:	US
Telephone Number	:	802-879-5151
Fax Number	:	866-561-8426

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. PAUL KENWORTHY
Credential	:	D.M.D.
Telephone Number	:	802-879-5151

Provider Enumeration Date	:	02/03/2014
Last Update Date	:	02/03/2014

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