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General NPI Number Information
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NPI Number | 1588928147
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN DENTAL CARE, PC
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Dates
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Enumeration Date | 06/28/2012
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Last Update Date | 06/28/2012
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Provider Practice Location Address
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Address Line | 336 BEDFORD ST
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City | LAKEVILLE
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State | MA
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Zip | 02347-2136
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Country | US
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Telephone | 508-947-5717
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Fax | 508-947-8405
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Provider Business Mailing Address
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Address Line | 336 BEDFORD ST
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City | LAKEVILLE
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State | MA
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Zip | 02347-2136
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Country | US
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Telephone | 508-947-5717
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Fax | 508-947-8405
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MINH-PHUONG BUI
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Credential | D.M.D.
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Telephone | 508-947-5717
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 21958
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License Number State | MA
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