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General NPI Number Information
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NPI Number | 1205868098
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Entity Type | Organization
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Legal Business Name | 42 NORTH DENTAL CARE, LLC
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Dates
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Enumeration Date | 07/06/2006
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Last Update Date | 06/21/2021
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Provider Practice Location Address
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Address Line | 200 5TH AVE
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City | WALTHAM
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State | MA
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Zip | 02451-8779
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Country | US
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Telephone | 781-647-0772
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Fax | 781-647-1086
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Provider Business Mailing Address
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Address Line | 200 5TH AVE
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City | WALTHAM
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State | MA
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Zip | 02451-8779
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Country | US
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Telephone | 781-647-0772
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Fax | 781-647-1086
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Authorized Official
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Title or Position | CHIEF CLINICAL OFFICER
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Name | DR. MICHAEL ANGELO SCIALABBA
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Credential | DDS
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Telephone | 561-512-2709
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 13328
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License Number State | MA
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