=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700335619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLA SHIKHANOVICH DMD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2016
-----------------------------------------------------
Last Update Date | 10/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 MAIN ST SUITE 101
-----------------------------------------------------
City | READING
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01867-3666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-944-4450
-----------------------------------------------------
Fax | 781-944-4451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 MAIN ST SUITE 101
-----------------------------------------------------
City | READING
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01867-3666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-944-4450
-----------------------------------------------------
Fax | 781-944-4451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ALLA SHIKHANOVICH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 781-944-4450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 22249
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------