=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255761730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK FRIED DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2013
-----------------------------------------------------
Last Update Date | 11/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 EDGELL RD
-----------------------------------------------------
City | FRAMINGHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01701-4834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-872-9339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 EDGELL RD
-----------------------------------------------------
City | FRAMINGHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01701-4834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-872-9339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK FRIED
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 508-872-9339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 15964
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------