Healthcare Provider Details

I. General information

NPI: 1588133946
Provider Name (Legal Business Name): MASSACHUSETTS INSTITUTE OF TECHNOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CARLETON ST
CAMBRIDGE MA
02142-1323
US

IV. Provider business mailing address

77 MASSACHUSETTS AVE # E23-431
CAMBRIDGE MA
02139-4301
US

V. Phone/Fax

Practice location:
  • Phone: 617-253-1501
  • Fax:
Mailing address:
  • Phone: 617-253-4481
  • 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 Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: BRIAN SCHUETZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 617-258-6609