Healthcare Provider Details

I. General information

NPI: 1871359935
Provider Name (Legal Business Name): JACQUELINE FLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BOYLSTON ST
BOSTON MA
02215-4302
US

IV. Provider business mailing address

125 WILMINGTON AVE
DORCHESTER MA
02124-4627
US

V. Phone/Fax

Practice location:
  • Phone: 617-927-6127
  • Fax:
Mailing address:
  • Phone: 781-964-3836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN10000801
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: