Healthcare Provider Details

I. General information

NPI: 1831022417
Provider Name (Legal Business Name): SMILES BY ROSIE VACCINATION CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 KENSINGTON AVE
SOMERVILLE MA
02145-2107
US

IV. Provider business mailing address

6 KENSINGTON AVE
SOMERVILLE MA
02145-2107
US

V. Phone/Fax

Practice location:
  • Phone: 617-684-5058
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: KATIE-ROSE WAGNER
Title or Position: IMMUNIZER
Credential: DDS
Phone: 617-684-5058