MEDICARE: WESTON ENDODONTICS, 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	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1992935910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTON ENDODONTICS, LLC

Provider Business Mailing Address
First Line	:	56 COLPITTS RD
Second Line	:
City	:	WESTON
State	:	MA
Zip	:	02493-1568
Country	:	US
Telephone Number	:	508-875-5863
Fax Number	:

Provider Business Practice Location Address
First Line	:	56 COLPITTS RD
Second Line	:
City	:	WESTON
State	:	MA
Zip	:	02493-1568
Country	:	US
Telephone Number	:	508-875-5863
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AYMAN ABOUSHALA
Credential	:	DMD, MS
Telephone Number	:	508-875-5863

Provider Enumeration Date	:	07/24/2009
Last Update Date	:	07/24/2009

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