MEDICARE: PRECIOUS BOSTON 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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	12054	NC

General Provider Information

NPI Number	:	1265051783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRECIOUS BOSTON DMD

Provider Business Mailing Address
First Line	:	8680 RACHEL FREEMAN WAY STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-9567
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8680 RACHEL FREEMAN WAY STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-9567
Country	:	US
Telephone Number	:	980-270-6511
Fax Number	:

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

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	08/30/2021

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