MEDICARE: AQUA DENTAL LLC

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	261QD0000X	Dental Clinic/Center	18450	MA

General Provider Information

NPI Number	:	1336392505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AQUA DENTAL LLC

Provider Business Mailing Address
First Line	:	1395 N MAIN ST
Second Line	:
City	:	RANDOLPH
State	:	MA
Zip	:	02368-1768
Country	:	US
Telephone Number	:	781-963-6077
Fax Number	:

Provider Business Practice Location Address
First Line	:	1395 N MAIN ST
Second Line	:
City	:	RANDOLPH
State	:	MA
Zip	:	02368-1768
Country	:	US
Telephone Number	:	781-963-6077
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JEFFREY FAYERMAN
Credential	:
Telephone Number	:	781-963-6077

Provider Enumeration Date	:	10/31/2008
Last Update Date	:	10/31/2008

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