Healthcare Provider Details

I. General information

NPI: 1770837015
Provider Name (Legal Business Name): KOBAD B MALESRA DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 CRANSTON ST
CRANSTON RI
02920-6758
US

IV. Provider business mailing address

1370 CRANSTON ST
CRANSTON RI
02920-6758
US

V. Phone/Fax

Practice location:
  • Phone: 401-946-1010
  • Fax:
Mailing address:
  • Phone: 401-946-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: KOBAD MALESRA
Title or Position: DENTIST
Credential: DDS
Phone: 401-946-1010