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General NPI Number Information
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NPI Number | 1104154780
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Entity Type | Organization
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Legal Business Name | ST.JOSEPH'S FAMILY DENTAL,LLC
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Dates
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Enumeration Date | 11/19/2009
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Last Update Date | 11/19/2009
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Provider Practice Location Address
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Address Line | 548 CHAPIN ST
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City | LUDLOW
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State | MA
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Zip | 01056-2524
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Country | US
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Telephone | 413-887-8318
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Fax | 413-737-3184
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Provider Business Mailing Address
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Address Line | 548 CHAPIN ST
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City | LUDLOW
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State | MA
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Zip | 01056-2524
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Country | US
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Telephone | 413-887-8318
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Fax | 413-737-3184
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Authorized Official
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Title or Position | DENTIST
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Name | DR. SUSANA R AGUERO
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Credential | D.D.S.
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Telephone | 413-737-3181
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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 | 21492
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License Number State | MA
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