Healthcare Provider Details

I. General information

NPI: 1598021156
Provider Name (Legal Business Name): HARVARD SCHOOL OF DENTAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 04/09/2012
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: 617-515-9993
  • Fax:
Mailing address:
  • Phone: 617-515-9993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDL11500
License Number StateMA

VIII. Authorized Official

Name: MRS. CATHERINE R LANE
Title or Position: ASSISTANT DEAN CLINICAL OPERATIONS
Credential:
Phone: 617-432-4276