Healthcare Provider Details

I. General information

NPI: 1043559412
Provider Name (Legal Business Name): DJKDMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MAIN ST
WILMINGTON MA
01887-3210
US

IV. Provider business mailing address

500 MAIN ST
WILMINGTON MA
01887-3210
US

V. Phone/Fax

Practice location:
  • Phone: 978-658-2569
  • Fax: 978-658-3913
Mailing address:
  • Phone: 978-658-2569
  • Fax: 978-658-3913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number20881
License Number StateMA

VIII. Authorized Official

Name: DR. DANIEL J KING
Title or Position: PRESIDENT
Credential: DMD
Phone: 978-658-2569