MEDICARE: DONNA M. PONTE PEREIRA, DMD, 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	1223P0300X	Periodontics	17461	MA

General Provider Information

NPI Number	:	1295971992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DONNA M. PONTE PEREIRA, DMD, LLC

Provider Business Mailing Address
First Line	:	825 CAMBRIDGE ST
Second Line	:
City	:	CAMBRIDGE
State	:	MA
Zip	:	02141-1429
Country	:	US
Telephone Number	:	617-492-7626
Fax Number	:

Provider Business Practice Location Address
First Line	:	826 CAMBRIDGE ST
Second Line	:
City	:	CAMBRIDGE
State	:	MA
Zip	:	02141-1402
Country	:	US
Telephone Number	:	617-492-7626
Fax Number	:	617-492-7629

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DONNA MARIE PONTE PEREIRA
Credential	:	DMD
Telephone Number	:	617-492-7626

Provider Enumeration Date	:	12/30/2008
Last Update Date	:	12/30/2008

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