Healthcare Provider Details

I. General information

NPI: 1164597217
Provider Name (Legal Business Name): RICHARD J SORBERA DDS SHILBY D MALOUF DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 BROADWAY
SOMERVILLE MA
01245-2812
US

IV. Provider business mailing address

366 BROADWAY
SOMERVILLE MA
01245-2812
US

V. Phone/Fax

Practice location:
  • Phone: 617-628-8000
  • Fax: 617-628-2370
Mailing address:
  • Phone: 617-628-8000
  • Fax: 617-628-2370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9458
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9637
License Number StateMA

VIII. Authorized Official

Name: DR. SHILBY D MALOUF JR.
Title or Position: VICE PRESIDENT
Credential: DDS
Phone: 617-628-8000