=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962414748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARRETT K PISKOR, DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2006
-----------------------------------------------------
Last Update Date | 01/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57 BEDFORD ST SUITE 208
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02420-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-862-1900
-----------------------------------------------------
Fax | 781-862-1817
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 BEDFORD ST SUITE 208
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02420-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-862-1900
-----------------------------------------------------
Fax | 781-862-1817
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GARRETT K PISKOR
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 617-547-4958
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 126900000X
-----------------------------------------------------
Taxonomy Name | Dental Laboratory Technician
-----------------------------------------------------
License Number | 12217
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 126900000X
-----------------------------------------------------
Taxonomy Name | Dental Laboratory Technician
-----------------------------------------------------
License Number | 15316
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------