Healthcare Provider Details

I. General information

NPI: 1932437936
Provider Name (Legal Business Name): BELMONT FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 TRAPELO RD
BELMONT MA
02478-4448
US

IV. Provider business mailing address

75 TRAPELO RD
BELMONT MA
02478-4448
US

V. Phone/Fax

Practice location:
  • Phone: 617-484-1796
  • Fax: 617-484-4130
Mailing address:
  • Phone: 617-484-1796
  • Fax: 617-484-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17482
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number20292
License Number StateMA

VIII. Authorized Official

Name: DR. JACQUELINE FICALORA
Title or Position: DENTIST
Credential: D.D.S
Phone: 617-484-1760