Healthcare Provider Details

I. General information

NPI: 1396215778
Provider Name (Legal Business Name): SHIELD PEDIATRIC DENTISTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

683 STATE RD
WESTPORT MA
02790-2848
US

IV. Provider business mailing address

683 STATE RD
WESTPORT MA
02790-2848
US

V. Phone/Fax

Practice location:
  • Phone: 617-548-6717
  • Fax:
Mailing address:
  • Phone: 617-548-6717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL GONZALEZ
Title or Position: OWNER
Credential: DMD
Phone: 617-548-6717