Healthcare Provider Details

I. General information

NPI: 1104689595
Provider Name (Legal Business Name): KAYLA SARGENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST
BOSTON MA
02111-1527
US

IV. Provider business mailing address

141 CENTRE ST
QUINCY MA
02169-6317
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN10001001
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number05250
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: