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General NPI Number Information
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NPI Number | 1205061207
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Entity Type | Organization
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Legal Business Name | COMMUNITY FAMILY DENTAL
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Dates
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Enumeration Date | 05/19/2009
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Last Update Date | 05/19/2009
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Provider Practice Location Address
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Address Line | 648 AMERICAN LEGION HWY
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City | ROSLINDALE
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State | MA
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Zip | 02131-3901
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Country | US
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Telephone | 617-699-9894
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Fax |
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Provider Business Mailing Address
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Address Line | 648 AMERICAN LEGION HWY
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City | ROSLINDALE
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State | MA
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Zip | 02131-3901
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Country | US
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Telephone | 617-699-9894
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ANDREY MAZO
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Credential | DMD
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Telephone | 617-285-6414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 18643
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License Number State | MA
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