Healthcare Provider Details

I. General information

NPI: 1124898440
Provider Name (Legal Business Name): DOVETAIL PAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 NEPONSET ST STE 3
CANTON MA
02021-1988
US

IV. Provider business mailing address

345 NEPONSET ST STE 3
CANTON MA
02021-1988
US

V. Phone/Fax

Practice location:
  • Phone: 781-747-8926
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: INDIA MICHEL
Title or Position: CO-FOUNDER
Credential:
Phone: 781-747-8926