Provider Demographics
NPI:1205015179
Name:SAMEKA DENTAL MANAGEMENT
Entity Type:Organization
Organization Name:SAMEKA DENTAL MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EKATERINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMULASHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-268-2333
Mailing Address - Street 1:500 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-4406
Mailing Address - Country:US
Mailing Address - Phone:617-268-2333
Mailing Address - Fax:617-268-8894
Practice Address - Street 1:500 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-4406
Practice Address - Country:US
Practice Address - Phone:617-268-2333
Practice Address - Fax:617-268-8894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty