MEDICARE: SMILE BOUTIQUE, 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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1447881339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE BOUTIQUE, PC

Provider Business Mailing Address
First Line	:	49 CHURCH ST
Second Line	:
City	:	WINCHESTER
State	:	MA
Zip	:	01890-2508
Country	:	US
Telephone Number	:	781-729-1444
Fax Number	:	781-729-1233

Provider Business Practice Location Address
First Line	:	49 CHURCH ST
Second Line	:
City	:	WINCHESTER
State	:	MA
Zip	:	01890-2508
Country	:	US
Telephone Number	:	781-729-1444
Fax Number	:	781-729-1233

Authorized Official
Title or Position	:	TREASURER
Name	:	MOJGAN RAHIMI
Credential	:	DMD
Telephone Number	:	781-729-1444

Provider Enumeration Date	:	01/29/2020
Last Update Date	:	01/29/2020

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