Healthcare Provider Details

I. General information

NPI: 1285170142
Provider Name (Legal Business Name): PEDIATRIC DENTAL OF MILLIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1098 MAIN ST
MILLIS MA
02054-1473
US

IV. Provider business mailing address

1098 MAIN ST
MILLIS MA
02054-1473
US

V. Phone/Fax

Practice location:
  • Phone: 508-376-1116
  • Fax:
Mailing address:
  • Phone: 508-376-1116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. NADIA DIAB SHAMARI
Title or Position: OWNER
Credential:
Phone: 508-376-1116