Provider Demographics
NPI:1164597217
Name:RICHARD J SORBERA DDS SHILBY D MALOUF DDS INC
Entity Type:Organization
Organization Name:RICHARD J SORBERA DDS SHILBY D MALOUF DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHILBY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MALOUF
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:617-628-8000
Mailing Address - Street 1:366 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01245-2812
Mailing Address - Country:US
Mailing Address - Phone:617-628-8000
Mailing Address - Fax:617-628-2370
Practice Address - Street 1:366 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:01245-2812
Practice Address - Country:US
Practice Address - Phone:617-628-8000
Practice Address - Fax:617-628-2370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA96371223S0112X
MA94581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX03044OtherRS
MA0202061Medicaid
MA0223573Medicaid
MAX03159OtherRS
MAX03044OtherRS
T56500Medicare UPIN
X03044Medicare ID - Type Unspecified
MA0223573Medicaid