Healthcare Provider Details

I. General information

NPI: 1972319481
Provider Name (Legal Business Name): WESTERN MASS PERIODONTICS & IMPLANT SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 SOUTH ST STE 1
PITTSFIELD MA
01201-8214
US

IV. Provider business mailing address

435 SOUTH ST STE 1
PITTSFIELD MA
01201-8214
US

V. Phone/Fax

Practice location:
  • Phone: 413-445-4592
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE BRANIGAN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 631-696-0100