=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568609071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE FORSYTH INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2009
-----------------------------------------------------
Last Update Date | 01/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 THE FENWAY
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02115-3782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-892-8383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 THE FENWAY
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02115-3782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-892-8383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | RICHARD NEIDERMAN
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 617-892-8374
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 10133
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------