=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710430087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANA KEOHANE DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2016
-----------------------------------------------------
Last Update Date | 08/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 319 LYNNWAY STE 1
-----------------------------------------------------
City | LYNN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01901-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-599-5437
-----------------------------------------------------
Fax | 781-599-5436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 LOWELL AVE
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02460-2150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-467-4702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN1857366
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------