=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275051450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARBORSIDE FAMILY DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2017
-----------------------------------------------------
Last Update Date | 09/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 WAMPANOAG TRL
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02915-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-431-2180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 WAMPANOAG TRL
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02915-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATIONS OFFICER
-----------------------------------------------------
Name | MS. SAMANTHA BURNELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-578-0274
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------