Healthcare Provider Details

I. General information

NPI: 1508958190
Provider Name (Legal Business Name): CHARLES B MILLSTEIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 MASSACHUSETTS AVE # 1
CAMBRIDGE MA
02138-2718
US

IV. Provider business mailing address

1648 MASSACHUSETTS AVE # 1
CAMBRIDGE MA
02138-2718
US

V. Phone/Fax

Practice location:
  • Phone: 617-876-4004
  • Fax: 617-984-2674
Mailing address:
  • Phone: 617-876-4004
  • Fax: 617-984-2674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number9719
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: