Healthcare Provider Details

I. General information

NPI: 1962323733
Provider Name (Legal Business Name): WAVERLY ENDODONTICS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BOYLSTON ST FL 2
BOSTON MA
02199-8081
US

IV. Provider business mailing address

45 1ST AVE APT 4
BOSTON MA
02129-4560
US

V. Phone/Fax

Practice location:
  • Phone: 617-841-8436
  • Fax:
Mailing address:
  • Phone: 617-955-3331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: GARRETT WAVERLY WINGROVE
Title or Position: ENDODONTIST
Credential: DMD, CAGS, MSD
Phone: 617-955-3331