Healthcare Provider Details

I. General information

NPI: 1700979978
Provider Name (Legal Business Name): WILLIAM MOSER PRENTISS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 CONSTITUTION LANE, SUITE 100C
DANVERS MA
01923
US

IV. Provider business mailing address

85 CONSTITUTION LANE, SUITE 100C
DANVERS MA
01923
US

V. Phone/Fax

Practice location:
  • Phone: 978-774-7033
  • Fax: 978-774-0341
Mailing address:
  • Phone: 978-774-7033
  • Fax: 978-774-0341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3725
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: