Healthcare Provider Details

I. General information

NPI: 1841194412
Provider Name (Legal Business Name): FORM DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 SOUTH ST
WALTHAM MA
02453-3537
US

IV. Provider business mailing address

75 CONANT RD
QUINCY MA
02171-1805
US

V. Phone/Fax

Practice location:
  • Phone: 781-899-2324
  • Fax:
Mailing address:
  • Phone: 781-351-1355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: PATRICK A REILLY
Title or Position: DENTIST, OWNER
Credential: DMD
Phone: 781-351-1355