Provider Demographics
NPI:1275819211
Name:WELLESLEY ENDODONTICS PC
Entity Type:Organization
Organization Name:WELLESLEY ENDODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOMALI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:781-237-1801
Mailing Address - Street 1:40 GROVE ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-7702
Mailing Address - Country:US
Mailing Address - Phone:781-237-1801
Mailing Address - Fax:
Practice Address - Street 1:40 GROVE ST
Practice Address - Street 2:SUITE 420
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-7702
Practice Address - Country:US
Practice Address - Phone:781-237-1801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17718261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental