Healthcare Provider Details

I. General information

NPI: 1760738298
Provider Name (Legal Business Name): ENIHOMO MARY OBADAN BDS, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 LONGWOOD AVE HARVARD DENTAL CENTER
BOSTON MA
02115-5819
US

IV. Provider business mailing address

188 LONGWOOD AVE HARVARD DENTAL CENTER
BOSTON MA
02115-5819
US

V. Phone/Fax

Practice location:
  • Phone: 617-669-9633
  • Fax:
Mailing address:
  • Phone: 617-669-9633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDL11652
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: