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General NPI Number Information
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NPI Number | 1326299702
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Entity Type | Organization
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Legal Business Name | DIBA DASTJERDI
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Dates
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Enumeration Date | 10/03/2008
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Last Update Date | 01/06/2009
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Provider Practice Location Address
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Address Line | 62 BURRILL ST
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City | SWAMPSCOTT
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State | MA
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Zip | 01907-1903
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Country | US
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Telephone | 781-599-4505
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Fax | 781-599-4945
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Provider Business Mailing Address
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Address Line | 62 BURRILL ST
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City | SWAMPSCOTT
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State | MA
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Zip | 01907-1903
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Country | US
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Telephone | 781-599-4505
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Fax | 781-599-4945
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Authorized Official
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Title or Position | INDEPENDANT CONTRACTOR/DENTIST
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Name | DIBA DASTJERDI
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Credential | D.M.D
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Telephone | 781-599-4505
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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 | 21835
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License Number State | MA
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