Healthcare Provider Details

I. General information

NPI: 1346410024
Provider Name (Legal Business Name): MS ORTHODONTICS ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MOUNT AUBURN ST SUITE 1A
WATERTOWN MA
02472-3968
US

IV. Provider business mailing address

106 MOUNT AUBURN ST SUITE 1A
WATERTOWN MA
02472-3968
US

V. Phone/Fax

Practice location:
  • Phone: 617-926-9500
  • Fax:
Mailing address:
  • Phone: 617-926-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number21077
License Number StateMA

VIII. Authorized Official

Name: DR. ANNA K SIMON
Title or Position: MEMBER
Credential: D.M.D.
Phone: 617-926-9500