Healthcare Provider Details

I. General information

NPI: 1780858639
Provider Name (Legal Business Name): JEFFERSON DENTAL ASSOCIATES, L.T.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 JEFFERSON BLVD
WARWICK RI
02888-3855
US

IV. Provider business mailing address

222 JEFFERSON BLVD
WARWICK RI
02888-3855
US

V. Phone/Fax

Practice location:
  • Phone: 401-739-2350
  • Fax:
Mailing address:
  • Phone: 401-739-2350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2610
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2654
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number1681
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1846
License Number StateRI

VIII. Authorized Official

Name: DR. MELVIN ERIC HANZEL
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 401-739-2350