MEDICARE: INTEGRATED ORAL HEALTH, 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	261QD0000X	Dental Clinic/Center	DN1857321	MA

General Provider Information

NPI Number	:	1174062848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED ORAL HEALTH, PC

Provider Business Mailing Address
First Line	:	270 LITTLETON RD
Second Line	:	SUITE 9
City	:	WESTFORD
State	:	MA
Zip	:	01886-3526
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	270 LITTLETON RD
Second Line	:	SUITE 9
City	:	WESTFORD
State	:	MA
Zip	:	01886-3526
Country	:	US
Telephone Number	:	617-642-9775
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DHEERAJ PAMIDIMUKKALA
Credential	:	DMD
Telephone Number	:	617-642-9775

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	02/14/2017

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