Healthcare Provider Details

I. General information

NPI: 1154331916
Provider Name (Legal Business Name): TRUSTEES OF BOSTON UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 03/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E NEWTON ST G407
BOSTON MA
02118-2308
US

IV. Provider business mailing address

100 E NEWTON ST G407
BOSTON MA
02118-2308
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-4352
  • Fax: 617-638-4365
Mailing address:
  • Phone: 617-638-4352
  • Fax: 617-638-4365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. PUSHKAR MEHRA
Title or Position: CHAIRMAN
Credential: DMD
Phone: 617-638-4352