MEDICARE: OCEAN STATE DENTAL HYGIENE SERVICES, LLC

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	124Q00000X	Dental Hygienist

General Provider Information

NPI Number	:	1063119071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEAN STATE DENTAL HYGIENE SERVICES, LLC

Provider Business Mailing Address
First Line	:	1522 ELMWOOD AVE
Second Line	:
City	:	CRANSTON
State	:	RI
Zip	:	02910-3819
Country	:	US
Telephone Number	:	401-827-9939
Fax Number	:

Provider Business Practice Location Address
First Line	:	1522 ELMWOOD AVE
Second Line	:
City	:	CRANSTON
State	:	RI
Zip	:	02910-3819
Country	:	US
Telephone Number	:	401-827-9939
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	NICOLE J PERIQUITO
Credential	:
Telephone Number	:	401-374-4151

Provider Enumeration Date	:	02/09/2023
Last Update Date	:	08/17/2023

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