Healthcare Provider Details

I. General information

NPI: 1871858233
Provider Name (Legal Business Name): DEREK NOBREGA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 PEACE ST
PROVIDENCE RI
02907-1510
US

IV. Provider business mailing address

825 CHALKSTONE AVE N. CAMPUS BUSINESS OFFICE, ATTN: R. SOARES
PROVIDENCE RI
02908-4728
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-4461
  • Fax: 401-456-4420
Mailing address:
  • Phone: 401-456-2525
  • Fax: 401-456-6742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberLD00081
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: