Healthcare Provider Details

I. General information

NPI: 1487712675
Provider Name (Legal Business Name): DRS DARVISH & GALLAGHER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LINCOLN STREET
WORCESTER MA
01605
US

IV. Provider business mailing address

200 LINCOLN STREET
WORCESTER MA
01605
US

V. Phone/Fax

Practice location:
  • Phone: 508-756-6264
  • Fax: 508-756-6490
Mailing address:
  • Phone: 508-756-6264
  • Fax: 508-756-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1053411798
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MANOUCH DARVISH
Title or Position: PRESIDENT
Credential:
Phone: 508-756-6264