MEDICARE: ELEMENT FAMILY DENTAL

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1598306490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEMENT FAMILY DENTAL

Provider Business Mailing Address
First Line	:	3860 MYSTIC VALLEY PKWY
Second Line	:	UNIT B
City	:	MEDFORD
State	:	MA
Zip	:	02155-5029
Country	:	US
Telephone Number	:	617-863-4410
Fax Number	:	617-863-4414

Provider Business Practice Location Address
First Line	:	3860 MYSTIC VALLEY PKWY
Second Line	:	UNIT B
City	:	MEDFORD
State	:	MA
Zip	:	02155-5029
Country	:	US
Telephone Number	:	617-863-4410
Fax Number	:	617-863-4414

Authorized Official
Title or Position	:	OWNER
Name	:	HARANCHAL K BAINS
Credential	:	DMD
Telephone Number	:	916-672-7417

Provider Enumeration Date	:	10/01/2019
Last Update Date	:	01/29/2020

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Directions to “ELEMENT FAMILY DENTAL ” Practice Location

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