Healthcare Provider Details

I. General information

NPI: 1063899128
Provider Name (Legal Business Name): KIDS ZONE DENTAL MA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SUTTON AVE
OXFORD MA
01540-1812
US

IV. Provider business mailing address

85 FRANKLIN ST
NEEDHAM MA
02494-2939
US

V. Phone/Fax

Practice location:
  • Phone: 508-499-8251
  • Fax:
Mailing address:
  • Phone: 508-499-8251
  • 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: SUPREETH VEERANNA
Title or Position: MEMBER
Credential: DMD
Phone: 508-499-8251