=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851071757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICROSURGICAL ENDODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2023
-----------------------------------------------------
Last Update Date | 07/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 607 BOYLSTON ST STE 202
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02116-3643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-236-7818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81 PINE ST APT 5
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02139-2740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | JUSTINE CHIOU
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 240-630-0364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------