Healthcare Provider Details

I. General information

NPI: 1366557712
Provider Name (Legal Business Name): HIROE BABA OHYAMA DMD, MMSC, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 LONGWOOD AVE
BOSTON MA
02115-5819
US

IV. Provider business mailing address

77 POND AVE APT 905
BROOKLINE MA
02445-7114
US

V. Phone/Fax

Practice location:
  • Phone: 617-432-1434
  • Fax: 617-432-4258
Mailing address:
  • Phone: 617-738-3342
  • Fax: 617-432-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20872
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: