Healthcare Provider Details

I. General information

NPI: 1396897823
Provider Name (Legal Business Name): MCNALLY BROTHERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 VAN DEENE AVE SUITE 201
WEST SPRINGFIELD MA
01089
US

IV. Provider business mailing address

75 VAN DEENE AVE SUITE 201
WEST SPRINGFIELD MA
01089-3213
US

V. Phone/Fax

Practice location:
  • Phone: 413-788-9621
  • Fax: 413-788-0103
Mailing address:
  • Phone: 413-788-9621
  • Fax: 413-788-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER R DESESA
Title or Position: PRESIDENT
Credential: DMD
Phone: 413-788-9621