Healthcare Provider Details

I. General information

NPI: 1043451289
Provider Name (Legal Business Name): PEDIATRIC&FAMILY DENTISTRY OF WOBURN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 ALFRED ST SUITE 210
WOBURN MA
01801-1976
US

IV. Provider business mailing address

7 ALFRED ST SUITE 210
WOBURN MA
01801-1976
US

V. Phone/Fax

Practice location:
  • Phone: 781-933-8380
  • Fax:
Mailing address:
  • Phone: 781-933-8380
  • 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

VIII. Authorized Official

Name: PATRICIA BUCKLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 781-933-8380