Healthcare Provider Details

I. General information

NPI: 1063963353
Provider Name (Legal Business Name): FITCHBURGH DENTISTRY AND BRACES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 JOHN FITCH HWY
FITCHBURG MA
01420-8403
US

IV. Provider business mailing address

5 MOUNT ROYAL AVE SUITE 300
MARLBOROUGH MA
01752-1981
US

V. Phone/Fax

Practice location:
  • Phone: 508-460-0632
  • Fax:
Mailing address:
  • Phone: 508-460-0632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: JOANNE TAVANO
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 978-580-1524