Healthcare Provider Details

I. General information

NPI: 1922548015
Provider Name (Legal Business Name): RHODE ISLAND CHILDREN'S DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 GALAXY PASS
SUTTON MA
01590-4836
US

IV. Provider business mailing address

27 GALAXY PASS
SUTTON MA
01590-4836
US

V. Phone/Fax

Practice location:
  • Phone: 401-828-1171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN1857501
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN17240
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN17240
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: REBECCA HORNE
Title or Position: MANAGER
Credential:
Phone: 508-792-8500