Provider Demographics
NPI:1235585969
Name:SALIB FANIKOS DENTAL CARE
Entity Type:Organization
Organization Name:SALIB FANIKOS DENTAL CARE
Other - Org Name:FANIKOS SALIB DENTAL CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURICE
Authorized Official - Middle Name:SALIB
Authorized Official - Last Name:FANIKOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-648-3878
Mailing Address - Street 1:905 GREAT PLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-3031
Mailing Address - Country:US
Mailing Address - Phone:781-343-7447
Mailing Address - Fax:781-343-7448
Practice Address - Street 1:905 GREAT PLAIN AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-3031
Practice Address - Country:US
Practice Address - Phone:781-343-7447
Practice Address - Fax:781-343-7448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN21751122300000X
MADN18552371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1740343854Medicare NSC