Healthcare Provider Details

I. General information

NPI: 1063498525
Provider Name (Legal Business Name): JAMIE MICHELE ITALIANE-DECUBELLIS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 S MAIN ST
COVENTRY RI
02816-5911
US

IV. Provider business mailing address

325 S MAIN ST
COVENTRY RI
02816-5911
US

V. Phone/Fax

Practice location:
  • Phone: 401-828-7070
  • Fax: 401-828-7125
Mailing address:
  • Phone: 401-828-7070
  • Fax: 401-828-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number02807
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: