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General NPI Number Information
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NPI Number | 1154664027
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Entity Type | Organization
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Legal Business Name | PARKWAY DENTAL LLC
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Dates
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Enumeration Date | 03/29/2013
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Last Update Date | 03/29/2013
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Provider Practice Location Address
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Address Line | 893 SOUTH ST
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City | ROSLINDALE
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State | MA
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Zip | 02131-2411
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Country | US
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Telephone | 617-323-3443
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Fax | 617-323-3350
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Provider Business Mailing Address
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Address Line | 893 SOUTH ST
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City | ROSLINDALE
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State | MA
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Zip | 02131-2411
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Country | US
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Telephone | 617-323-3443
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Fax | 617-323-3350
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Authorized Official
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Title or Position | OWNER
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Name | DR. RAMESH IZEDIAN
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Credential | D.M.D.
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Telephone | 508-676-8268
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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 | 18174
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License Number State | MA
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