Healthcare Provider Details

I. General information

NPI: 1124573456
Provider Name (Legal Business Name): MISS ESRA M. FADEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST
BOSTON MA
02111-1527
US

IV. Provider business mailing address

75 STATION LNDG APT. 526, MEDFORD, MA
MEDFORD MA
02155-5127
US

V. Phone/Fax

Practice location:
  • Phone: 617-817-0656
  • Fax:
Mailing address:
  • Phone: 617-817-0656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number13-J-D-0030293
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: