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General NPI Number Information
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NPI Number | 1396051439
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Entity Type | Organization
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Legal Business Name | ELITE ORTHODONTICS, LLC
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Dates
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Enumeration Date | 08/26/2010
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Last Update Date | 08/26/2010
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Provider Practice Location Address
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Address Line | 107 EASTERN AVE
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City | DEDHAM
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State | MA
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Zip | 02026-4515
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Country | US
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Telephone | 781-686-1733
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Fax | 781-686-1726
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Provider Business Mailing Address
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Address Line | 107 EASTERN AVE
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City | DEDHAM
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State | MA
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Zip | 02026-4515
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Country | US
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Telephone | 781-686-1733
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Fax | 781-686-1726
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Authorized Official
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Title or Position | MANAGER
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Name | DR. EMAD ABDALLAH
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Credential | D.M.D., M.S.
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Telephone | 781-686-1733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 21655
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License Number State | MA
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