MEDICARE: CITIDENTAL BROOKLINE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223P0300X	Periodontics
3	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1255954178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITIDENTAL BROOKLINE PLLC

Provider Business Mailing Address
First Line	:	63 COURT ST
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02108-2109
Country	:	US
Telephone Number	:	617-943-9868
Fax Number	:

Provider Business Practice Location Address
First Line	:	637 WASHINGTON ST STE 210
Second Line	:
City	:	BROOKLINE
State	:	MA
Zip	:	02446-4579
Country	:	US
Telephone Number	:	617-566-4420
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	LINA BADAWI
Credential	:
Telephone Number	:	617-817-3312

Provider Enumeration Date	:	05/27/2020
Last Update Date	:	05/27/2020

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