Healthcare Provider Details

I. General information

NPI: 1740485655
Provider Name (Legal Business Name): KIDS DENTAL CARE OF FALL RIVER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 06/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 ROBESON ST
FALL RIVER MA
02720-5497
US

IV. Provider business mailing address

PO BOX 1909
NORTH FALMOUTH MA
02556-1909
US

V. Phone/Fax

Practice location:
  • Phone: 508-676-0111
  • Fax:
Mailing address:
  • Phone: 508-676-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number16809
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. MICHAEL ANTHONY BUCCINO
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: DDS, MSD
Phone: 508-676-0111