MEDICARE: 42 NORTH DENTAL CARE, LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1992156467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	42 NORTH DENTAL CARE, LLC

Provider Business Mailing Address
First Line	:	200 5TH AVE FL 3
Second Line	:
City	:	WALTHAM
State	:	MA
Zip	:	02451-8759
Country	:	US
Telephone Number	:	781-647-0772
Fax Number	:

Provider Business Practice Location Address
First Line	:	477 WASHINGTON ST
Second Line	:
City	:	ABINGTON
State	:	MA
Zip	:	02351-2417
Country	:	US
Telephone Number	:	781-878-2190
Fax Number	:

Authorized Official
Title or Position	:	CHIEF CLINICAL OFFICER
Name	:	DR. MICHAEL ANGELO SCIALABBA
Credential	:	DDS
Telephone Number	:	561-512-2709

Provider Enumeration Date	:	06/27/2016
Last Update Date	:	06/21/2021

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