MEDICARE: OCEAN STATE DENTAL GROUP INC

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	122300000X	Dentist	2584	RI

General Provider Information

NPI Number	:	1972664894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCEAN STATE DENTAL GROUP INC

Provider Business Mailing Address
First Line	:	1522 ELMWOOD AVE
Second Line	:
City	:	CRANSTON
State	:	RI
Zip	:	02910
Country	:	US
Telephone Number	:	401-467-6363
Fax Number	:	401-467-7613

Provider Business Practice Location Address
First Line	:	1522 ELMWOOD AVE
Second Line	:
City	:	CRANSTON
State	:	RI
Zip	:	02910
Country	:	US
Telephone Number	:	401-467-6363
Fax Number	:	401-467-7613

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PETER JOHN DALLESANDRO
Credential	:	DDS
Telephone Number	:	401-467-6363

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	08/22/2020

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