=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811504830
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESSEX DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2020
-----------------------------------------------------
Last Update Date | 09/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 PICKERING ST
-----------------------------------------------------
City | ESSEX
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01929-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-768-6525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 ANDREW ST APT 2F
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01970-4376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-695-8612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | DR. DAVID JOHN KONEFAL
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 413-695-8612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------