Healthcare Provider Details

I. General information

NPI: 1073730297
Provider Name (Legal Business Name): PARADISE DENTAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142A CANAL STREET
SALEM MA
01970
US

IV. Provider business mailing address

142A CANAL STREET
SALEM MA
01970
US

V. Phone/Fax

Practice location:
  • Phone: 781-598-3700
  • Fax: 781-598-3730
Mailing address:
  • Phone: 781-598-3700
  • Fax: 781-598-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17992
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number17953
License Number StateMA

VIII. Authorized Official

Name: DR. STEPHEN MARK HAMELBURG
Title or Position: MANAGING PARTNER
Credential: D.M.D.
Phone: 781-598-3700