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General NPI Number Information
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NPI Number | 1295907467
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Entity Type | Organization
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Legal Business Name | MATTAPAN SQUARE FAMILY DENTAL PC
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Dates
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Enumeration Date | 03/28/2008
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Last Update Date | 03/28/2008
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Provider Practice Location Address
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Address Line | 1634 BLUE HILL AVE
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City | MATTAPAN
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State | MA
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Zip | 02126-2121
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Country | US
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Telephone | 617-298-2000
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Fax | 617-298-2002
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Provider Business Mailing Address
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Address Line | 1634 BLUE HILL AVE
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City | MATTAPAN
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State | MA
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Zip | 02126-2121
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Country | US
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Telephone | 617-298-2000
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Fax | 617-298-2002
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Authorized Official
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Title or Position | MANAGER
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Name | ALEX FAIGEL
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Credential |
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Telephone | 617-823-2111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 20485
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License Number State | MA
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