Healthcare Provider Details

I. General information

NPI: 1164512570
Provider Name (Legal Business Name): PRESIDENT AND FELLOWS OF HARVARD COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 LONGWOOD AVE
BOSTON MA
02115-5819
US

IV. Provider business mailing address

188 LONGWOOD AVE
BOSTON MA
02115-5819
US

V. Phone/Fax

Practice location:
  • Phone: 617-432-1434
  • Fax: 617-432-4258
Mailing address:
  • Phone: 617-432-1434
  • Fax: 617-432-4258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12762
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17724
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number16638
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number16484
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14710
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9239
License Number StateMA

VIII. Authorized Official

Name: DR. JOHN DA SILVA
Title or Position: MEDICAL DIRECTOR
Credential: DMD
Phone: 617-432-1440