Healthcare Provider Details

I. General information

NPI: 1205868098
Provider Name (Legal Business Name): 42 NORTH DENTAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 5TH AVE
WALTHAM MA
02451-8779
US

IV. Provider business mailing address

200 5TH AVE
WALTHAM MA
02451-8779
US

V. Phone/Fax

Practice location:
  • Phone: 781-647-0772
  • Fax: 781-647-1086
Mailing address:
  • Phone: 781-647-0772
  • Fax: 781-647-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13328
License Number StateMA

VIII. Authorized Official

Name: DR. MICHAEL ANGELO SCIALABBA
Title or Position: CHIEF CLINICAL OFFICER
Credential: DDS
Phone: 561-512-2709