Healthcare Provider Details

I. General information

NPI: 1740682517
Provider Name (Legal Business Name): CAPE COD PERIODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 WILLOW ST
YARMOUTH PORT MA
02675-1757
US

IV. Provider business mailing address

244 WILLOW ST
YARMOUTH PORT MA
02675-1757
US

V. Phone/Fax

Practice location:
  • Phone: 508-375-9090
  • Fax: 508-375-3323
Mailing address:
  • Phone: 508-375-9090
  • Fax: 508-375-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN1855923
License Number StateMA

VIII. Authorized Official

Name: DR. JOE A NGUYEN
Title or Position: DENTIST/OWNDER
Credential: DMD
Phone: 858-761-2404