Healthcare Provider Details

I. General information

NPI: 1306136106
Provider Name (Legal Business Name): DR. DENTAL OF ENDICOTT PLAZA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 ENDICOTT ST
DANVERS MA
01923-4803
US

IV. Provider business mailing address

139 ENDICOTT ST
DANVERS MA
01923-4803
US

V. Phone/Fax

Practice location:
  • Phone: 617-887-2100
  • Fax: 617-887-2102
Mailing address:
  • Phone: 617-887-2100
  • Fax: 617-887-2102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number20485
License Number StateMA

VIII. Authorized Official

Name: JULIA O FAIGEL
Title or Position: DMD / OWNER
Credential: DMD
Phone: 617-887-2100