Healthcare Provider Details

I. General information

NPI: 1558470161
Provider Name (Legal Business Name): SOUTH SHORE ENDODONTICS BRAINTREE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FRANKLIN STREET SUITE 300
BRAIN TREE MA
02184
US

IV. Provider business mailing address

400 FRANKLIN STREET SUITE 300
BRAIN TREE MA
02184
US

V. Phone/Fax

Practice location:
  • Phone: 781-849-3051
  • Fax: 781-356-7039
Mailing address:
  • Phone: 781-849-3051
  • Fax: 781-356-7039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number14725
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier826203
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED CONCORDIA
# 2
Identifier100402
Identifier TypeOTHER
Identifier State
Identifier IssuerDELTA DENTAL
# 3
IdentifierX10469
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS OF MA

VIII. Authorized Official

Name: DAVID J STARLINE
Title or Position: PARTNER ENDODONTIST
Credential: DMD
Phone: 781-849-3051