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General NPI Number Information
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NPI Number | 1013258359
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Entity Type | Organization
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Legal Business Name | DAVIS SQUARE DENTAL SPECIALISTS
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 03/12/2013
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Provider Practice Location Address
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Address Line | 1792 DORCHESTER AVE
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City | DORCHESTER
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State | MA
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Zip | 02124-2533
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Country | US
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Telephone | 617-265-8338
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Fax |
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Provider Business Mailing Address
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Address Line | 30 COLLEGE AVE
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City | SOMERVILLE
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State | MA
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Zip | 02144-1914
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MOUHAB Z RIZKALLAH
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Credential |
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Telephone | 617-764-2247
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 20416
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License Number State | MA
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