MEDICARE: PROF. SERGE DIBART D.M.D. D.D.S.

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	1223P0300X	Periodontics	17572	MA

General Provider Information

NPI Number	:	1598898793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. SERGE DIBART D.M.D. D.D.S.

Provider Business Mailing Address
First Line	:	106 MOUNT AUBURN ST
Second Line	:
City	:	WATERTOWN
State	:	MA
Zip	:	02472-3968
Country	:	US
Telephone Number	:	617-926-1013
Fax Number	:	617-926-6739

Provider Business Practice Location Address
First Line	:	106 MOUNT AUBURN ST
Second Line	:
City	:	WATERTOWN
State	:	MA
Zip	:	02472-3968
Country	:	US
Telephone Number	:	617-926-1013
Fax Number	:	617-926-6739

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

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	07/08/2007

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