Provider Demographics
NPI:1174251714
Name:KERSEY, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KERSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 W SIDE RD
Mailing Address - Street 2:
Mailing Address - City:WELD
Mailing Address - State:ME
Mailing Address - Zip Code:04285-3436
Mailing Address - Country:US
Mailing Address - Phone:207-585-2412
Mailing Address - Fax:
Practice Address - Street 1:94 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2630
Practice Address - Country:US
Practice Address - Phone:207-807-8164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH4240124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist