=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285170142
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC DENTAL OF MILLIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2017
-----------------------------------------------------
Last Update Date | 01/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1098 MAIN ST
-----------------------------------------------------
City | MILLIS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02054-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-376-1116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1098 MAIN ST
-----------------------------------------------------
City | MILLIS
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02054-1473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-376-1116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NADIA DIAB SHAMARI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 508-376-1116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------