Healthcare Provider Details

I. General information

NPI: 1255608048
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 E MILTON RD APT 2
BROOKLINE MA
02445-6738
US

IV. Provider business mailing address

11 E MILTON RD APT 2
BROOKLINE MA
02445-6738
US

V. Phone/Fax

Practice location:
  • Phone: 508-333-4331
  • Fax:
Mailing address:
  • Phone: 508-333-4331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberS17991895
License Number StateMA

VIII. Authorized Official

Name: DR. BRANDON DAVID GRUNES
Title or Position: DENTAL RESIDENT
Credential: DMD
Phone: 617-355-4426