Healthcare Provider Details

I. General information

NPI: 1770945404
Provider Name (Legal Business Name): NITHYA MINNAH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 NEWBURY ST STE 501
BOSTON MA
02116-2971
US

IV. Provider business mailing address

115 NEWBURY ST STE 501
BOSTON MA
02116-2971
US

V. Phone/Fax

Practice location:
  • Phone: 617-536-0365
  • Fax:
Mailing address:
  • Phone: 617-536-0365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: NITHYA MINNAH
Title or Position: ORTHODONTIST/OWNER
Credential:
Phone: 617-536-0365