MEDICARE: CONVIVIAL DENTAL 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	261QM1300X	Multi-Specialty Clinic/Center	DN1855922	MA
2	261QD0000X	Dental Clinic/Center	DN1855922	MA

General Provider Information

NPI Number	:	1689007908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONVIVIAL DENTAL PC

Provider Business Mailing Address
First Line	:	64 PINE ST
Second Line	:
City	:	DOVER
State	:	MA
Zip	:	02030-2426
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1244 BOYLSTON ST STE 205
Second Line	:
City	:	CHESTNUT HILL
State	:	MA
Zip	:	02467-2115
Country	:	US
Telephone Number	:	617-818-0573
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ATHANASIOS ZAVRAS
Credential	:	D.D.S, M.S, D.M.SC
Telephone Number	:	617-818-0573

Provider Enumeration Date	:	08/11/2013
Last Update Date	:	08/11/2013

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Directions to “CONVIVIAL DENTAL PC ” Practice Location

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