MEDICARE: MAVERICK FAMILY DENTAL 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	1223G0001X	General Practice Dentistry	20485	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912058421
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAVERICK FAMILY DENTAL PC

Provider Business Mailing Address
First Line	:	45 MAVERICK SQ
Second Line	:
City	:	EAST BOSTON
State	:	MA
Zip	:	02128-2312
Country	:	US
Telephone Number	:	617-567-3800
Fax Number	:	617-567-3802

Provider Business Practice Location Address
First Line	:	45 MAVERICK SQ
Second Line	:
City	:	EAST BOSTON
State	:	MA
Zip	:	02128-2312
Country	:	US
Telephone Number	:	617-567-3800
Fax Number	:	617-567-3802

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JULIA FAIGEL
Credential	:	DMD
Telephone Number	:	617-567-3800

Provider Enumeration Date	:	01/13/2007
Last Update Date	:	04/03/2008

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Directions to “MAVERICK FAMILY DENTAL PC ” Practice Location

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