Healthcare Provider Details

I. General information

NPI: 1801871314
Provider Name (Legal Business Name): MICHAEL B KOIDIN D.D.S., M.SC.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 BROAD ST
LYNN MA
01902-5003
US

IV. Provider business mailing address

PO BOX 233
SWAMPSCOTT MA
01907-0333
US

V. Phone/Fax

Practice location:
  • Phone: 781-599-2900
  • Fax: 781-598-1670
Mailing address:
  • Phone: 781-599-2900
  • Fax: 781-598-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12700
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: