Healthcare Provider Details

I. General information

NPI: 1083486658
Provider Name (Legal Business Name): OTSUBO SHIKA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 FARNSWORTH ST
BOSTON MA
02210-1211
US

IV. Provider business mailing address

1400 CENTRE ST STE 103
NEWTON CENTER MA
02459-2414
US

V. Phone/Fax

Practice location:
  • Phone: 617-802-6888
  • Fax:
Mailing address:
  • Phone: 857-294-5497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YUKO OTSUBO
Title or Position: MEMBER
Credential: DMD
Phone: 857-294-5497