MEDICARE: SAMEKA DENTAL MANAGEMENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	21211	MA

General Provider Information

NPI Number	:	1205015179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAMEKA DENTAL MANAGEMENT

Provider Business Mailing Address
First Line	:	500 E BROADWAY
Second Line	:
City	:	SOUTH BOSTON
State	:	MA
Zip	:	02127-4406
Country	:	US
Telephone Number	:	617-268-2333
Fax Number	:	617-268-8894

Provider Business Practice Location Address
First Line	:	500 E BROADWAY
Second Line	:
City	:	SOUTH BOSTON
State	:	MA
Zip	:	02127-4406
Country	:	US
Telephone Number	:	617-268-2333
Fax Number	:	617-268-8894

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. EKATERINA MAMULASHVILI
Credential	:	DMD
Telephone Number	:	617-268-2333

Provider Enumeration Date	:	10/29/2007
Last Update Date	:	10/29/2007

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