=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891059036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKLINE PROGRESSIVE DENTAL TEAM P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2012
-----------------------------------------------------
Last Update Date | 07/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1203 BEACON ST STE 1
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02446-5346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-232-8113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1203 BEACON ST STE 1
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02446-5346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. HYEJIN KWAK
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 617-232-8113
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 21553
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------