Healthcare Provider Details

I. General information

NPI: 1952880361
Provider Name (Legal Business Name): EVERETT FAMILY DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 BROADWAY
EVERETT MA
02149-3614
US

IV. Provider business mailing address

5 MOUNT ROYAL AVE STE 300
MARLBOROUGH MA
01752-1900
US

V. Phone/Fax

Practice location:
  • Phone: 617-389-2005
  • Fax: 617-389-1007
Mailing address:
  • Phone: 508-460-0632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN20209
License Number StateMA

VIII. Authorized Official

Name: MS. JOANNE TAVANO
Title or Position: CFO
Credential:
Phone: 978-580-1524