Healthcare Provider Details

I. General information

NPI: 1780838193
Provider Name (Legal Business Name): MICHAEL JOSEPH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1692 MASSACHUSETTS AVE
CAMBRIDGE MA
02138-1878
US

IV. Provider business mailing address

1692 MASSACHUSETTS AVE
CAMBRIDGE MA
02138-1878
US

V. Phone/Fax

Practice location:
  • Phone: 617-492-3616
  • Fax: 617-492-8415
Mailing address:
  • Phone: 617-492-3616
  • Fax: 617-492-8415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number21090
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: