=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063418085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDY RUTH CHENEY DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2005
-----------------------------------------------------
Last Update Date | 01/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 WARREN ST
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02135-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-254-3800
-----------------------------------------------------
Fax | 617-779-1484
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 SOMERSET RD
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02445-4513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-566-5011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 19265
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 19265
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------