Healthcare Provider Details

I. General information

NPI: 1700847563
Provider Name (Legal Business Name): NATALIE M STAUB RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: NATALIE MATTA RDH

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 BEACON ST SUITE 409
BROOKLINE MA
02446-5685
US

IV. Provider business mailing address

81 GREGORY ST
WALTHAM MA
02451-2151
US

V. Phone/Fax

Practice location:
  • Phone: 617-277-0033
  • Fax:
Mailing address:
  • Phone: 617-869-5662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number10358
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: