Healthcare Provider Details

I. General information

NPI: 1518269810
Provider Name (Legal Business Name): WEST SOMERVILLE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 11/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 COLLEGE AVE
SOMERVILLE MA
02144-1919
US

IV. Provider business mailing address

124 COLLEGE AVE
SOMERVILLE MA
02144-1919
US

V. Phone/Fax

Practice location:
  • Phone: 617-625-0543
  • Fax: 617-666-5034
Mailing address:
  • Phone: 617-625-0543
  • Fax: 617-666-5034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number StateMA

VIII. Authorized Official

Name: DR. MARHAMA ALVI-SHAH
Title or Position: OWNER
Credential:
Phone: 617-625-0543