Provider Demographics
NPI:1396035705
Name:SOUTH SHORE DENTAL PROSTHETIC
Entity Type:Organization
Organization Name:SOUTH SHORE DENTAL PROSTHETIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVLICIC
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-471-1890
Mailing Address - Street 1:165 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5514
Mailing Address - Country:US
Mailing Address - Phone:617-471-1890
Mailing Address - Fax:617-471-7310
Practice Address - Street 1:165 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5514
Practice Address - Country:US
Practice Address - Phone:617-471-1890
Practice Address - Fax:617-471-7310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21265122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty