Healthcare Provider Details

I. General information

NPI: 1831534379
Provider Name (Legal Business Name): SALEM PEDIATRIC DENTAL & ORTHODONTIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 HIGHLAND AVE
SALEM MA
01970-2723
US

IV. Provider business mailing address

116 HIGHLAND AVE
SALEM MA
01970-2723
US

V. Phone/Fax

Practice location:
  • Phone: 978-745-7363
  • Fax: 978-745-8470
Mailing address:
  • Phone: 978-745-7363
  • Fax: 978-745-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number20954
License Number StateMA

VIII. Authorized Official

Name: JASON GOULD
Title or Position: OWNER
Credential:
Phone: 978-745-7363