Healthcare Provider Details

I. General information

NPI: 1326171109
Provider Name (Legal Business Name): WITT ORTHODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 MAIN ST
HOLDEN MA
01520-1090
US

IV. Provider business mailing address

1406 MAIN ST
HOLDEN MA
01520-1090
US

V. Phone/Fax

Practice location:
  • Phone: 508-829-7650
  • Fax: 508-829-4616
Mailing address:
  • Phone: 508-829-7650
  • Fax: 508-829-4616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number17900
License Number StateMA

VIII. Authorized Official

Name: DAVIS W WITT
Title or Position: PRESIDENT
Credential: DMD MSD
Phone: 508-829-7650