Healthcare Provider Details

I. General information

NPI: 1053517037
Provider Name (Legal Business Name): PROSTHODONTICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 ENON ST
BEVERLY MA
01915-1116
US

IV. Provider business mailing address

16 ENON ST
BEVERLY MA
01915-1116
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-6726
  • Fax: 978-922-6727
Mailing address:
  • Phone: 978-922-6726
  • Fax: 978-922-6727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number17559
License Number StateMA

VIII. Authorized Official

Name: MS. MARY-LOU COURCELLE
Title or Position: OFFICE MANAGER
Credential:
Phone: 978-922-6726