MEDICARE: MALDEN DENTAL CENTER

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

General Provider Information

NPI Number	:	1366693558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALDEN DENTAL CENTER

Provider Business Mailing Address
First Line	:	427 MAIN ST
Second Line	:
City	:	MALDEN
State	:	MA
Zip	:	02148-5012
Country	:	US
Telephone Number	:	781-322-5070
Fax Number	:

Provider Business Practice Location Address
First Line	:	427 MAIN ST
Second Line	:
City	:	MALDEN
State	:	MA
Zip	:	02148-5012
Country	:	US
Telephone Number	:	781-322-5070
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. EKATERINA MAMULASHVILI
Credential	:	D.M.D
Telephone Number	:	781-322-5070

Provider Enumeration Date	:	10/06/2008
Last Update Date	:	10/06/2008

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Directions to “MALDEN DENTAL CENTER ” Practice Location

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