MEDICARE: DR. MICHAEL MISTRETTA DMD

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	122300000X	Dentist	DN1858355	MA

General Provider Information

NPI Number	:	1235791716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL MISTRETTA DMD

Provider Business Mailing Address
First Line	:	333 GREAT RIVER RD APT 434
Second Line	:
City	:	SOMERVILLE
State	:	MA
Zip	:	02145-1223
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	688 HANCOCK ST
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02170-2814
Country	:	US
Telephone Number	:	813-468-0143
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2019
Last Update Date	:	03/31/2021

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