Healthcare Provider Details

I. General information

NPI: 1356368229
Provider Name (Legal Business Name): JONATHAN STUART BAMEL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 COLUMBUS ST
NORTH HIGHLANDS MA
02461
US

IV. Provider business mailing address

28 WINSTON RD
NEWTON MA
02459
US

V. Phone/Fax

Practice location:
  • Phone: 617-965-3225
  • Fax: 617-965-7501
Mailing address:
  • Phone: 617-969-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number15467
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: