Healthcare Provider Details

I. General information

NPI: 1649345711
Provider Name (Legal Business Name): NORTHEAST ENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 FAUNCE CORNER RD
N. DARTMOUTH MA
02747
US

IV. Provider business mailing address

299 FAUNCE CORNER RD
N. DARTMOUTH MA
02747
US

V. Phone/Fax

Practice location:
  • Phone: 508-995-0700
  • Fax: 508-995-3070
Mailing address:
  • Phone: 508-995-0700
  • Fax: 508-995-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. DEBORAH CORNWALL
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 508-207-4462