=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841194412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORM DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2026
-----------------------------------------------------
Last Update Date | 10/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 SOUTH ST
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02453-3537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-899-2324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 CONANT RD
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02171-1805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-351-1355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST, OWNER
-----------------------------------------------------
Name | PATRICK A REILLY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 781-351-1355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------