Healthcare Provider Details

I. General information

NPI: 1922315910
Provider Name (Legal Business Name): SCITUATE PERIODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2010
Last Update Date: 09/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 NEW DRIFTWAY SUITE 201
SCITUATE MA
02066-4533
US

IV. Provider business mailing address

56 NEW DRIFTWAY SUITE 201
SCITUATE MA
02066-4533
US

V. Phone/Fax

Practice location:
  • Phone: 781-545-7800
  • Fax: 781-545-7801
Mailing address:
  • Phone: 781-545-7800
  • Fax: 781-545-7801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number20988
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MOHAMED HASSAN
Title or Position: OWNER
Credential: DMD,BDS,MS,FICD
Phone: 781-545-7800