Healthcare Provider Details

I. General information

NPI: 1548662224
Provider Name (Legal Business Name): DR. RESHMA MENON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST FL 6
BOSTON MA
02111-1527
US

IV. Provider business mailing address

188 LONGWOOD AVE HSDM
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDF12049
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: