Healthcare Provider Details

I. General information

NPI: 1316111974
Provider Name (Legal Business Name): MICHELLE BENTO LAVALL, DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WALNUT ST
FALL RIVER MA
02720-2418
US

IV. Provider business mailing address

164 WALNUT ST
FALL RIVER MA
02720-2418
US

V. Phone/Fax

Practice location:
  • Phone: 508-679-2906
  • Fax:
Mailing address:
  • Phone: 508-679-2906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number19261
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11711
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBLUE CROSS
# 2
Identifier8517-3
Identifier TypeOTHER
Identifier StateRI
Identifier IssuerBLUE CROSS OF RI

VIII. Authorized Official

Name: KATHY SYDE
Title or Position: MANAGER
Credential:
Phone: 508-679-2906