Healthcare Provider Details

I. General information

NPI: 1053462358
Provider Name (Legal Business Name): SOUTH SHORE ORAL SURGERY ASSOCIATES CO. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 QUINCY AVE
QUINCY MA
02169-8127
US

IV. Provider business mailing address

270 QUINCY AVE
QUINCY MA
02169-8127
US

V. Phone/Fax

Practice location:
  • Phone: 617-773-9500
  • Fax: 617-773-2827
Mailing address:
  • Phone: 617-773-9500
  • Fax: 617-773-2827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number17663
License Number StateMA

VIII. Authorized Official

Name: DR. DAVID PAUL LUSTBADER
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 617-773-9500