Healthcare Provider Details

I. General information

NPI: 1982907762
Provider Name (Legal Business Name): SHAWSHEEN FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 12/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 MAIN ST
TEWKSBURY MA
01876-4769
US

IV. Provider business mailing address

1455 MAIN ST
TEWKSBURY MA
01876-4769
US

V. Phone/Fax

Practice location:
  • Phone: 978-851-7112
  • Fax: 978-851-2811
Mailing address:
  • Phone: 978-851-7112
  • Fax: 978-851-2811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number20116
License Number StateMA

VIII. Authorized Official

Name: CARLA BUSTILLO-GONZALEZ
Title or Position: OWNER
Credential: D.D.S.
Phone: 978-851-7112