=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538278510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKLINE PERIODENTAL ASSOC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1443 BEACON ST
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02446-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-232-8222
-----------------------------------------------------
Fax | 617-277-2027
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1443 BEACON STREET
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-232-8222
-----------------------------------------------------
Fax | 617-277-2027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. MARILYN JEAN MENTO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-232-8222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------