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General NPI Number Information
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NPI Number | 1740629724
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Entity Type | Organization
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Legal Business Name | WOBURN STREET DENTAL, PC
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Dates
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Enumeration Date | 06/23/2013
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Last Update Date | 06/23/2013
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Provider Practice Location Address
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Address Line | 18 WOBURN ST
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City | MEDFORD
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State | MA
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Zip | 02155-3428
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Country | US
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Telephone | 781-396-1414
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Fax | 781-396-9238
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Provider Business Mailing Address
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Address Line | 18 WOBURN ST
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City | MEDFORD
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State | MA
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Zip | 02155-3428
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Country | US
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Telephone | 781-396-1414
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Fax | 781-396-9238
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Authorized Official
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Title or Position | OWNER
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Name | BORIS BACANURSCHI
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Credential | DMD
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Telephone | 781-396-1414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 21583
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License Number State | MA
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