MEDICARE: AGMO DENTAL GROUP PC

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	:	1588218895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGMO DENTAL GROUP PC

Provider Business Mailing Address
First Line	:	629 MASSACHUSETTS AVE
Second Line	:
City	:	BOXBOROUGH
State	:	MA
Zip	:	01719-1528
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	629 MASSACHUSETTS AVE
Second Line	:
City	:	BOXBOROUGH
State	:	MA
Zip	:	01719-1528
Country	:	US
Telephone Number	:	978-263-8950
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. ABDUL RAHMAN ADDAS
Credential	:	DMD
Telephone Number	:	513-560-0858

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	07/25/2019

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