Healthcare Provider Details

I. General information

NPI: 1881342608
Provider Name (Legal Business Name): NICOLE JEANNE GRACIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BOYLSTON ST
BOSTON MA
02215-4302
US

IV. Provider business mailing address

53 MOUNT VERNON ST UNIT 2
BOSTON MA
02108-1300
US

V. Phone/Fax

Practice location:
  • Phone: 617-267-0900
  • Fax:
Mailing address:
  • Phone: 616-648-5231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1859801
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: