Provider Demographics
NPI:1376919696
Name:EL SHADDAI DENTAL ASSOCIATES MATTAPAN PC
Entity Type:Organization
Organization Name:EL SHADDAI DENTAL ASSOCIATES MATTAPAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:O
Authorized Official - Last Name:OLATUNJI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-298-1955
Mailing Address - Street 1:542 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-3014
Mailing Address - Country:US
Mailing Address - Phone:617-298-1955
Mailing Address - Fax:617-296-6004
Practice Address - Street 1:542 RIVER ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-3014
Practice Address - Country:US
Practice Address - Phone:617-298-1955
Practice Address - Fax:617-296-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN19621122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty