Healthcare Provider Details

I. General information

NPI: 1154806289
Provider Name (Legal Business Name): GIANGRASSO DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 HANOVER ST
BOSTON MA
02113-1810
US

IV. Provider business mailing address

279 HANOVER ST
BOSTON MA
02113-1810
US

V. Phone/Fax

Practice location:
  • Phone: 617-227-6410
  • Fax:
Mailing address:
  • Phone: 617-227-6410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: LUCIA GIANGRASSO
Title or Position: OFFICE MANAGER
Credential:
Phone: 617-227-6410