=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730468430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDOVER FAMILY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2011
-----------------------------------------------------
Last Update Date | 08/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 HAVERHILL ST STE 1
-----------------------------------------------------
City | ANDOVER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01810-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-470-2233
-----------------------------------------------------
Fax | 978-470-2212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 HAVERHILL ST STE 1
-----------------------------------------------------
City | ANDOVER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01810-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-470-2233
-----------------------------------------------------
Fax | 978-470-2212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MANU SHARMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 978-434-1385
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 19195
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------