Healthcare Provider Details

I. General information

NPI: 1164440517
Provider Name (Legal Business Name): ELLIOT W SALLOWAY DMD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ELM ST STE 203
WORCESTER MA
01609
US

IV. Provider business mailing address

111 ELM ST STE 203
WORCESTER MA
01609
US

V. Phone/Fax

Practice location:
  • Phone: 508-752-1302
  • Fax: 508-753-5801
Mailing address:
  • Phone: 508-752-1302
  • Fax: 508-753-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9215
License Number StateMA

VIII. Authorized Official

Name: DR. ELLIOT W SALLOWAY
Title or Position: PRESIDENT TREASURER
Credential: DMD
Phone: 508-752-1302