MEDICARE: WOLLASTON DENTAL CARE, INC

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	20147	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	X11526	OTHER	MA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1871765966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOLLASTON DENTAL CARE, INC

Provider Business Mailing Address
First Line	:	688 HANCOCK ST
Second Line	:
City	:	QUINCY
State	:	MA
Zip	:	02170-2814
Country	:	US
Telephone Number	:	617-984-5888
Fax Number	:	617-984-5822

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	:	617-984-5822

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JENNIFER LEE
Credential	:	DMD
Telephone Number	:	617-984-5888

Provider Enumeration Date	:	03/28/2008
Last Update Date	:	03/28/2008

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