=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124672779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLISHED DNTL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2019
-----------------------------------------------------
Last Update Date | 07/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 AGNES LN
-----------------------------------------------------
City | CHATHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02633-1502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-237-5378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 936
-----------------------------------------------------
City | WEST CHATHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02669-0936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-237-5378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELLEN D GOULD
-----------------------------------------------------
Credential | RDH
-----------------------------------------------------
Telephone | 508-237-5378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------