Healthcare Provider Details

I. General information

NPI: 1578582623
Provider Name (Legal Business Name): ORTHODONTIC SPECIALISTS OF SOUTHEASTERN MASSACHUSETTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2856 ACUSHNET AVE
NEW BEDFORD MA
02745-1618
US

IV. Provider business mailing address

2856 ACUSHNET AVE
NEW BEDFORD MA
02745-1618
US

V. Phone/Fax

Practice location:
  • Phone: 508-998-1232
  • Fax:
Mailing address:
  • Phone: 508-998-1232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KELLY GWOZDZ
Title or Position: SECRETARY
Credential:
Phone: 508-998-1232