Healthcare Provider Details

I. General information

NPI: 1568904571
Provider Name (Legal Business Name): SHAGHALIAN FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 PAWTUCKET AVE
RUMFORD RI
02916-1704
US

IV. Provider business mailing address

1002 PAWTUCKET AVE
RUMFORD RI
02916-1704
US

V. Phone/Fax

Practice location:
  • Phone: 401-438-4964
  • Fax: 401-434-6021
Mailing address:
  • Phone: 401-438-4964
  • Fax: 401-434-6021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN02886
License Number StateRI

VIII. Authorized Official

Name: DR. JUSTIN W SHAGHALIAN
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 401-438-4964