Healthcare Provider Details

I. General information

NPI: 1689007908
Provider Name (Legal Business Name): CONVIVIAL DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2013
Last Update Date: 08/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 BOYLSTON ST STE 205
CHESTNUT HILL MA
02467-2115
US

IV. Provider business mailing address

64 PINE ST
DOVER MA
02030-2426
US

V. Phone/Fax

Practice location:
  • Phone: 617-818-0573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN1855922
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberDN1855922
License Number StateMA

VIII. Authorized Official

Name: DR. ATHANASIOS ZAVRAS
Title or Position: PRESIDENT
Credential: D.D.S, M.S, D.M.SC
Phone: 617-818-0573