Healthcare Provider Details

I. General information

NPI: 1215379375
Provider Name (Legal Business Name): EAGLE ENDODONTICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 MUZZEY ST 210
LEXINGTON MA
02421-5256
US

IV. Provider business mailing address

108 4TH ST
MEDFORD MA
02155-5018
US

V. Phone/Fax

Practice location:
  • Phone: 781-863-2453
  • Fax:
Mailing address:
  • Phone: 617-767-4829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number21378
License Number StateMA

VIII. Authorized Official

Name: ALI SARRAF
Title or Position: PRESIDENT
Credential: DMD
Phone: 617-767-4829