Healthcare Provider Details

I. General information

NPI: 1093993503
Provider Name (Legal Business Name): BOSTON UNIVERSITY'S DEPARTMENT OF ORAL AND MAXILOFACIAL PATHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E NEWTON ST RM G-04
BOSTON MA
02118-2308
US

IV. Provider business mailing address

PO BOX 1167 GOLDTHWAIT ASSOC C/O BU ORAL AND MAXILOFACIAL PATHOLOGY
MARBLEHEAD MA
01945
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-4775
  • Fax:
Mailing address:
  • Phone: 781-631-8210
  • Fax: 781-639-2103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4954
License Number StateMA

VIII. Authorized Official

Name: DR. JEFFREY W. HUTTER
Title or Position: DEAN AD INTERIM
Credential: DMD, MED
Phone: 617-638-4780