Basic Information
| Provider Information | |||||||||
| NPI: | 1780032136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KASENCHAK | ||||||||
| FirstName: | MARY JO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2144 CECIL B MOORE AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191214014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153206187 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2144 CECIL B MOORE AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191214014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153206187 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2016 | ||||||||
| LastUpdateDate: | 12/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS040790 | PA | Y | Dental Providers | Dentist |
No ID Information.