MEDICARE: TERISA JOSE

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	122300000X	Dentist	DN1859421	MA

General Provider Information

NPI Number	:	1467191007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERISA JOSE

Provider Business Mailing Address
First Line	:	59 SAFFORD ST
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02170-1007
Country	:	US
Telephone Number	:	347-479-5629
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	:	617-984-5888
Fax Number	:

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

Provider Enumeration Date	:	06/01/2022
Last Update Date	:	07/16/2022

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Directions to “ TERISA JOSE ” Practice Location

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