Healthcare Provider Details

I. General information

NPI: 1285196642
Provider Name (Legal Business Name): SEAPORT ORTHODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 SUMMER ST
BOSTON MA
02210-1108
US

IV. Provider business mailing address

25 NORTHERN AVE UNIT 1209
BOSTON MA
02210-1994
US

V. Phone/Fax

Practice location:
  • Phone: 617-752-2220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ELLA OSBORN
Title or Position: OWNER/DOCTOR
Credential: DMD
Phone: 781-254-6804