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General NPI Number Information
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NPI Number | 1730544743
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTAL PROFESSIONALS LLC
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Dates
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Enumeration Date | 12/17/2015
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Last Update Date | 12/17/2015
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Provider Practice Location Address
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Address Line | 391 LYNN WAY BLDG A
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City | LYNN
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State | MA
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Zip | 01901
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Country | US
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Telephone | 617-393-5437
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Fax |
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Provider Business Mailing Address
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Address Line | 575 MOUNT AUBURN ST STE 201
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City | CAMBRIDGE
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State | MA
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Zip | 02138-4627
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Country | US
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Telephone | 617-393-5437
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | PEDRAM JAVEDAN
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Credential | DDS, FAAPD
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Telephone | 617-393-5437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN-1855617
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License Number State | MA
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