Healthcare Provider Details

I. General information

NPI: 1972664563
Provider Name (Legal Business Name): HARVARD VANGUARD MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 GROSSMAN DR
BRAINTREE MA
02184-4997
US

IV. Provider business mailing address

275 GROVE ST SUITE 3-300
AUBURNDALE MA
02466-2272
US

V. Phone/Fax

Practice location:
  • Phone: 781-849-2255
  • Fax: 781-849-2566
Mailing address:
  • Phone: 617-559-8096
  • Fax: 617-421-3487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DEBRA GEIHSLER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 617-559-8012