Healthcare Provider Details

I. General information

NPI: 1174210603
Provider Name (Legal Business Name): ROYAL DENTAL BROOKLINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 BEACON ST STE 306
BROOKLINE MA
02446-5622
US

IV. Provider business mailing address

15 LIBERTY DR
SOUTHBOROUGH MA
01772-4005
US

V. Phone/Fax

Practice location:
  • Phone: 617-608-3463
  • Fax:
Mailing address:
  • Phone: 517-316-6314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DHARA SHAH
Title or Position: PARTNER
Credential: DMD
Phone: 517-316-6314