=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336225739
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER A DELLI COLLI DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 164 NORTH MAIN ST
-----------------------------------------------------
City | NATICK
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-653-6263
-----------------------------------------------------
Fax | 508-652-1970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 164 NORTH MAIN ST
-----------------------------------------------------
City | NATICK
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-653-6263
-----------------------------------------------------
Fax | 508-652-1970
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12208
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------