MEDICARE: SALIB FANIKOS DENTAL CARE

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	1223P0221X	Pediatric Dentistry	DN1855237	MA
2	122300000X	Dentist	DN21751	MA

General Provider Information

NPI Number	:	1235585969
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALIB FANIKOS DENTAL CARE

Provider Business Mailing Address
First Line	:	905 GREAT PLAIN AVE
Second Line	:
City	:	NEEDHAM
State	:	MA
Zip	:	02492-3031
Country	:	US
Telephone Number	:	781-343-7447
Fax Number	:	781-343-7448

Provider Business Practice Location Address
First Line	:	905 GREAT PLAIN AVE
Second Line	:
City	:	NEEDHAM
State	:	MA
Zip	:	02492-3031
Country	:	US
Telephone Number	:	781-343-7447
Fax Number	:	781-343-7448

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. LAURICE SALIB FANIKOS
Credential	:	D.M.D.
Telephone Number	:	508-648-3878

Provider Enumeration Date	:	05/12/2016
Last Update Date	:	05/12/2016

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