Healthcare Provider Details

I. General information

NPI: 1568409902
Provider Name (Legal Business Name): MELROSE WAKEFIELD ORAL SURGERY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 MAIN ST
MELROSE MA
02176-2711
US

IV. Provider business mailing address

810 MAIN ST
MELROSE MA
02176-2711
US

V. Phone/Fax

Practice location:
  • Phone: 781-662-6228
  • Fax: 781-662-4455
Mailing address:
  • Phone: 781-662-6228
  • Fax: 781-662-4455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: JANET NIGHTINGALE
Title or Position: MANAGER
Credential:
Phone: 781-662-6228