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General NPI Number Information
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NPI Number | 1396035705
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Entity Type | Organization
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Legal Business Name | SOUTH SHORE DENTAL PROSTHETIC
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Dates
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Enumeration Date | 04/19/2011
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Last Update Date | 04/19/2011
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Provider Practice Location Address
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Address Line | 165 WASHINGTON ST
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City | QUINCY
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State | MA
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Zip | 02169-5514
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Country | US
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Telephone | 617-471-1890
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Fax | 617-471-7310
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Provider Business Mailing Address
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Address Line | 165 WASHINGTON ST
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City | QUINCY
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State | MA
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Zip | 02169-5514
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Country | US
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Telephone | 617-471-1890
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Fax | 617-471-7310
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KATARINA PAVLICIC
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Credential | DMD
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Telephone | 617-471-1890
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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 | 21265
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License Number State | MA
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