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General NPI Number Information
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NPI Number | 1679744668
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Entity Type | Organization
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Legal Business Name | MYSTIC VALLEY ORTHODONTICS
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Dates
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Enumeration Date | 03/18/2008
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Last Update Date | 03/18/2008
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Provider Practice Location Address
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Address Line | 80 HIGH ST SUITE 2
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City | MEDFORD
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State | MA
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Zip | 02155-3872
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Country | US
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Telephone | 781-396-9230
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Fax | 781-391-6090
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Provider Business Mailing Address
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Address Line | 80 HIGH ST SUITE 2
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City | MEDFORD
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State | MA
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Zip | 02155-3872
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | NA
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Name | DR. JOY ELIZABETH KASPARIAN-FEDERICO
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Credential | D.M.D.
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Telephone | 781-396-9230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 19234
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License Number State | MA
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