=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184051153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE BRACES PLACE OF LAWRENCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2013
-----------------------------------------------------
Last Update Date | 10/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 GEORGE ST
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01852-2228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-454-0774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 COLLEGE AVE
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02144-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOUHAB RIZKALLAH
-----------------------------------------------------
Credential | DDS MSD PC
-----------------------------------------------------
Telephone | 617-591-9999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 20416
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------