=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528826245
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNRISE DENTAL PARTNERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2024
-----------------------------------------------------
Last Update Date | 03/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 MAIN ST STE 6B
-----------------------------------------------------
City | PEABODY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01960-5653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-587-3330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 OAK LEAF WAY
-----------------------------------------------------
City | PEABODY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01960-4939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | LARISA SEREDKINA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 978-729-1541
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------