Provider Demographics
NPI:1871970145
Name:PAUL KENWORTHY DMD PC
Entity type:Organization
Organization Name:PAUL KENWORTHY DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KENWORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-879-5151
Mailing Address - Street 1:4 KELLOGG RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-2815
Mailing Address - Country:US
Mailing Address - Phone:802-879-5151
Mailing Address - Fax:866-561-8426
Practice Address - Street 1:1 PLACE NOTRE DAME
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-2223
Practice Address - Country:US
Practice Address - Phone:802-879-5151
Practice Address - Fax:866-561-8426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT975332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2551Medicaid
VT6196380004Medicare NSC