=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053803825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRANSTON PEDIATRIC DENTISTRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2018
-----------------------------------------------------
Last Update Date | 06/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67 PHENIX AVE
-----------------------------------------------------
City | CRANSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02920-4233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-818-0573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 PINE ST
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02030-2426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-818-0573
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ATHANASIOS ZAVRAS
-----------------------------------------------------
Credential | DDS, MS, DMSC
-----------------------------------------------------
Telephone | 617-818-0573
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | DEN03342
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------