MEDICARE: HIROE BABA OHYAMA DMD, MMSC, PHD

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	1223G0001X	General Practice Dentistry	20872	MA

General Provider Information

NPI Number	:	1366557712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HIROE BABA OHYAMA DMD, MMSC, PHD

Provider Business Mailing Address
First Line	:	77 POND AVE APT 905
Second Line	:
City	:	BROOKLINE
State	:	MA
Zip	:	02445-7114
Country	:	US
Telephone Number	:	617-738-3342
Fax Number	:	617-432-0901

Provider Business Practice Location Address
First Line	:	188 LONGWOOD AVE
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02115-5819
Country	:	US
Telephone Number	:	617-432-1434
Fax Number	:	617-432-4258

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	07/08/2007

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