Healthcare Provider Details

I. General information

NPI: 1467162040
Provider Name (Legal Business Name): MEOLA DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1576 COMMONWEALTH AVE
BRIGHTON MA
02135-5004
US

IV. Provider business mailing address

1576 COMMONWEALTH AVE
BRIGHTON MA
02135-5004
US

V. Phone/Fax

Practice location:
  • Phone: 617-232-7399
  • Fax: 617-232-7917
Mailing address:
  • Phone: 617-232-7399
  • Fax: 617-232-7917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ERIN RAINES
Title or Position: COO
Credential:
Phone: 781-893-7500