=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487057311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WISSANEE JIA-MAHASAP DDS,MS,FACP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2014
-----------------------------------------------------
Last Update Date | 04/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 188 LONGWOOD AVE
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02115-5819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-432-1434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 CAMERON ST APT 301
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02445-7667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-581-8954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | DF100062
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------