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General NPI Number Information
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NPI Number | 1821601170
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Entity Type | Organization
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Legal Business Name | CLEAN AND SEAL DENTAL PROGRAM
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Dates
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Enumeration Date | 08/26/2020
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Last Update Date | 08/26/2020
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Provider Practice Location Address
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Address Line | 172 ASHMONT ST
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City | DORCHESTER
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State | MA
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Zip | 02124-3745
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Country | US
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Telephone | 774-321-4720
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Fax |
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Provider Business Mailing Address
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Address Line | 172 ASHMONT ST
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City | DORCHESTER
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State | MA
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Zip | 02124-3745
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Country | US
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Telephone | 774-321-4720
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Fax |
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Authorized Official
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Title or Position | PUBLIC HEALTH DENTAL HYGIENIST
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Name | FAITH BROOKS
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Credential | RDH, BSDH, M.ED
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Telephone | 774-321-4720
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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