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General NPI Number Information
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NPI Number | 1144369109
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTAL ASSOCIATES OF BROOKLINE, PC
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1684 BEACON ST
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City | BROOKLINE
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State | MA
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Zip | 02445-2101
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Country | US
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Telephone | 617-232-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 1684 BEACON ST
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City | BROOKLINE
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State | MA
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Zip | 02445-2101
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Country | US
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Telephone | 617-232-7100
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JOHN FICARELLI
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Credential | DMD
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Telephone | 617-232-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 12246
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License Number State | MA
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