Healthcare Provider Details

I. General information

NPI: 1780188508
Provider Name (Legal Business Name): THE BRACES PLACE OF LAWRENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 CHATHAM ST
LYNN MA
01902-2139
US

IV. Provider business mailing address

30 COLLEGE AVE
SOMERVILLE MA
02144-1914
US

V. Phone/Fax

Practice location:
  • Phone: 781-599-1177
  • Fax:
Mailing address:
  • Phone: 617-591-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN20416
License Number StateMA

VIII. Authorized Official

Name: MRS. JULIANA MASIELLO
Title or Position: CORPORATE MANAGER
Credential:
Phone: 617-591-9999