Healthcare Provider Details

I. General information

NPI: 1215416672
Provider Name (Legal Business Name): MALDEN DENTISTRY AND BRACES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 MAIN ST
MALDEN MA
02148-5012
US

IV. Provider business mailing address

5 MOUNT ROYAL AVE STE 300
MARLBOROUGH MA
01752-1900
US

V. Phone/Fax

Practice location:
  • Phone: 781-322-5070
  • Fax:
Mailing address:
  • Phone: 508-460-0632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN20209
License Number StateMA

VIII. Authorized Official

Name: MS. JOANNE TAVANO
Title or Position: CFO
Credential:
Phone: 978-580-1524